Provider Demographics
NPI:1417733015
Name:MORADI, MANDANA (PSYD)
Entity Type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:MORADI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 GAVIOTA AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1423
Mailing Address - Country:US
Mailing Address - Phone:310-254-4647
Mailing Address - Fax:
Practice Address - Street 1:3303 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1704
Practice Address - Country:US
Practice Address - Phone:213-283-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16239103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical