Provider Demographics
NPI:1346738234
Name:MOALLEM, BAHARAK ISABEL (PHD)
Entity Type:Individual
Prefix:
First Name:BAHARAK
Middle Name:ISABEL
Last Name:MOALLEM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 EAST RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-6010
Mailing Address - Country:US
Mailing Address - Phone:713-486-2700
Mailing Address - Fax:
Practice Address - Street 1:1941 EAST RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-6010
Practice Address - Country:US
Practice Address - Phone:713-486-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2023-10-09
Deactivation Date:2018-06-12
Deactivation Code:
Reactivation Date:2020-02-13
Provider Licenses
StateLicense IDTaxonomies
NY021081103T00000X
TX39920103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist