Provider Demographics
NPI:1346625035
Name:GHIYAM, SHIRIN
Entity Type:Individual
Prefix:
First Name:SHIRIN
Middle Name:
Last Name:GHIYAM
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 1:630 CRICKETFIELD CT
Mailing Address - Street 2:
Mailing Address - City:LAKE SHERWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5156
Mailing Address - Country:US
Mailing Address - Phone:805-368-2063
Mailing Address - Fax:
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:805-368-2063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF87702103T00000X
CALMFT91196103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist