Provider Demographics
NPI:1124564067
Name:BANIASADI, ROBERT BEHYAD (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BEHYAD
Last Name:BANIASADI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:BANIASADI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8510 BALBOA BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-3583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 E JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5113
Practice Address - Country:US
Practice Address - Phone:805-373-0725
Practice Address - Fax:805-373-0574
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10280225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant