Provider Demographics
NPI:1538317359
Name:FARAZIAN, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FARAZIAN
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 1:15339 SATICOY ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3345
Mailing Address - Country:US
Mailing Address - Phone:818-267-2646
Mailing Address - Fax:818-267-2791
Practice Address - Street 1:15339 SATICOY ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3345
Practice Address - Country:US
Practice Address - Phone:818-267-2646
Practice Address - Fax:818-267-2791
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA84875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL SECURITY NUMBER