Provider Demographics
NPI:1134658065
Name:DR AZADEH GOLSHANI PSYCHOLOGIST PC
Entity Type:Organization
Organization Name:DR AZADEH GOLSHANI PSYCHOLOGIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:AZADEH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLSHANI
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-927-9853
Mailing Address - Street 1:11045 MISSOURI AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5625
Mailing Address - Country:US
Mailing Address - Phone:310-927-9853
Mailing Address - Fax:
Practice Address - Street 1:3415 S SEPULVEDA BLVD STE 1100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-7090
Practice Address - Country:US
Practice Address - Phone:310-927-9853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28464261QM0801X, 261QM0850X
261QM0855X
PSY28464261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder