Provider Demographics
NPI:1518406875
Name:SOURIS, SEPIDEH A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SEPIDEH
Middle Name:A
Last Name:SOURIS
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 1:21243 VENTURA BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-2123
Mailing Address - Country:US
Mailing Address - Phone:310-993-3620
Mailing Address - Fax:747-300-9246
Practice Address - Street 1:21243 VENTURA BLVD STE 107
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-2123
Practice Address - Country:US
Practice Address - Phone:310-993-3620
Practice Address - Fax:747-300-9246
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14946103T00000X
CAPSY14946103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14946OtherPROFESSIONAL LICENSE