Provider Demographics
NPI:1558631747
Name:JALALI BIDGOLI, SHAHRZAD
Entity Type:Individual
Prefix:MISS
First Name:SHAHRZAD
Middle Name:
Last Name:JALALI BIDGOLI
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 1:10625 KINNARD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5908
Mailing Address - Country:US
Mailing Address - Phone:310-849-0801
Mailing Address - Fax:
Practice Address - Street 1:812 W TOWN AND COUNTRY RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4712
Practice Address - Country:US
Practice Address - Phone:714-547-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)