Provider Demographics
NPI:1154866465
Name:HATIFI, SHANAZ
Entity Type:Individual
Prefix:
First Name:SHANAZ
Middle Name:
Last Name:HATIFI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SUTTON WAY APT 220
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4188
Mailing Address - Country:US
Mailing Address - Phone:510-393-5796
Mailing Address - Fax:
Practice Address - Street 1:210 SUTTON WAY APT 220
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4188
Practice Address - Country:US
Practice Address - Phone:510-393-5796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD2101371101Y00000X, 101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health