Provider Demographics
NPI:1255470381
Name:CHAVOSHIAN, ALI-REZA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALI-REZA
Middle Name:
Last Name:CHAVOSHIAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 DURANT AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1725
Mailing Address - Country:US
Mailing Address - Phone:510-845-2409
Mailing Address - Fax:
Practice Address - Street 1:2955 SHATTUCK AVE
Practice Address - Street 2:#1
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1808
Practice Address - Country:US
Practice Address - Phone:510-845-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15984103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA762204OtherMEDICAL
CA762204OtherMEDICAL