Provider Demographics
NPI:1407570393
Name:EDELWEISS INDIVIDUAL AND FAMILY THERAPY
Entity Type:Organization
Organization Name:EDELWEISS INDIVIDUAL AND FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEDMARRIAGEANDFAMILYTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SABA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTAZERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:949-229-0567
Mailing Address - Street 1:15615 ALTON PKWY STE 450
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3308
Mailing Address - Country:US
Mailing Address - Phone:949-229-0567
Mailing Address - Fax:
Practice Address - Street 1:1100 QUAIL ST STE 206
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2782
Practice Address - Country:US
Practice Address - Phone:949-229-0567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health