Provider Demographics
NPI:1508116518
Name:EHTESHAMZADEH, SIAMAK
Entity Type:Individual
Prefix:
First Name:SIAMAK
Middle Name:
Last Name:EHTESHAMZADEH
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:PO BOX 8461
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-8461
Mailing Address - Country:US
Mailing Address - Phone:951-217-9363
Mailing Address - Fax:
Practice Address - Street 1:25320 LURIN AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-2405
Practice Address - Country:US
Practice Address - Phone:951-217-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YA0400X, 103TF0000X
CAPSB37425103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical