Provider Demographics
NPI:1558515338
Name:FARAHANI, AVID G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AVID
Middle Name:G
Last Name:FARAHANI
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 1:18946 TUBA ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-1230
Mailing Address - Country:US
Mailing Address - Phone:503-575-1317
Mailing Address - Fax:503-388-4144
Practice Address - Street 1:10260 SW GREENBURG RD STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5514
Practice Address - Country:US
Practice Address - Phone:503-575-1317
Practice Address - Fax:503-388-4144
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23456103TC0700X
OR2166103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500633704Medicaid
ORR159192Medicare PIN
ORR178809Medicare PIN
OR500633704Medicaid