Provider Demographics
NPI:1154685907
Name:FARAH, BASIM ABRAHAM (MA CLINICAL PSY)
Entity Type:Individual
Prefix:
First Name:BASIM
Middle Name:ABRAHAM
Last Name:FARAH
Suffix:
Gender:M
Credentials:MA CLINICAL PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 WILD BILL WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-4561
Mailing Address - Country:US
Mailing Address - Phone:971-344-7914
Mailing Address - Fax:
Practice Address - Street 1:1800 GRAVENSTEIN HWY N
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-2607
Practice Address - Country:US
Practice Address - Phone:707-634-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSB94022610103T00000X
CAPSB 94022610225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist