Provider Demographics
NPI:1376841296
Name:MOGHADDAM, PEGAH (PSY D)
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:MOGHADDAM
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 BARCLAY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-7145
Mailing Address - Country:US
Mailing Address - Phone:770-458-8711
Mailing Address - Fax:770-458-8640
Practice Address - Street 1:4536 BARCLAY DR
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7145
Practice Address - Country:US
Practice Address - Phone:770-458-8711
Practice Address - Fax:770-458-8640
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist