Provider Demographics
NPI:1326358094
Name:AHMADSHAHI, MIKE M (PH D)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:M
Last Name:AHMADSHAHI
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15233 VENTURA BLVD
Mailing Address - Street 2:SUITE 1204
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2201
Mailing Address - Country:US
Mailing Address - Phone:310-923-0623
Mailing Address - Fax:818-990-5143
Practice Address - Street 1:15233 VENTURA BLVD
Practice Address - Street 2:SUITE 1204
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2201
Practice Address - Country:US
Practice Address - Phone:310-923-0623
Practice Address - Fax:818-990-5143
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25362103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical