Provider Demographics
NPI:1346640950
Name:EBRAHIMI, AZADEH
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:EBRAHIMI
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 1:11810 BALBOA BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2753
Mailing Address - Country:US
Mailing Address - Phone:818-923-2090
Mailing Address - Fax:
Practice Address - Street 1:12821 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3012
Practice Address - Country:US
Practice Address - Phone:818-432-5025
Practice Address - Fax:818-760-9092
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA116249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health