Provider Demographics
NPI:1508639485
Name:KIANDOLI, MAMALEH
Entity Type:Individual
Prefix:
First Name:MAMALEH
Middle Name:
Last Name:KIANDOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10318 W SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-8423
Mailing Address - Country:US
Mailing Address - Phone:623-703-3513
Mailing Address - Fax:
Practice Address - Street 1:10318 W SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-8423
Practice Address - Country:US
Practice Address - Phone:623-703-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH8874106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician