Provider Demographics
NPI:1326398496
Name:GILBERT, MITRA YAZDI (PSYD,, MS)
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:YAZDI
Last Name:GILBERT
Suffix:
Gender:F
Credentials:PSYD,, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18839
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-0839
Mailing Address - Country:US
Mailing Address - Phone:610-844-6511
Mailing Address - Fax:
Practice Address - Street 1:801 W GIRARD AVE
Practice Address - Street 2:STE#103
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-4212
Practice Address - Country:US
Practice Address - Phone:215-787-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00601800103T00000X
PAPS017057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist