Provider Demographics
NPI:1194008276
Name:GHANNADI, SHIRIN (PSYD)
Entity Type:Individual
Prefix:
First Name:SHIRIN
Middle Name:
Last Name:GHANNADI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 9TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6476
Mailing Address - Country:US
Mailing Address - Phone:916-651-9476
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:10333 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5808
Practice Address - Country:US
Practice Address - Phone:805-468-2000
Practice Address - Fax:805-466-6011
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A777971OtherMEDICARE IN - TYPE UNSPECIFIED
CAH59376OtherMEDICARE UPIN