Provider Demographics
NPI:1114434792
Name:POURABEDIN, ASHKAN ADAM
Entity Type:Individual
Prefix:
First Name:ASHKAN
Middle Name:ADAM
Last Name:POURABEDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2849 DOIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-1016
Mailing Address - Country:US
Mailing Address - Phone:510-223-9579
Mailing Address - Fax:
Practice Address - Street 1:3075 CITRUS CIR STE 240
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2667
Practice Address - Country:US
Practice Address - Phone:925-256-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-15-07844106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty