Provider Demographics
NPI:1467715672
Name:JAVANFARD, ELAN
Entity Type:Individual
Prefix:MR
First Name:ELAN
Middle Name:
Last Name:JAVANFARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-4820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:310-390-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
390200000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator