Provider Demographics
NPI:1376711861
Name:SOLTANIAN, AVO AVEH (MFT)
Entity Type:Individual
Prefix:MR
First Name:AVO
Middle Name:AVEH
Last Name:SOLTANIAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:AVEH
Other - Middle Name:
Other - Last Name:SOLTANIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:138 N BRAND BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4621
Mailing Address - Country:US
Mailing Address - Phone:818-937-1095
Mailing Address - Fax:818-660-1085
Practice Address - Street 1:138 N BRAND BLVD STE 303
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-937-1095
Practice Address - Fax:818-660-1085
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 45151106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC45151OtherBOARD OF BEHAVIORAL SCIENCES
CA929793Medicaid