Provider Demographics
NPI:1558905950
Name:BAVARSAD, SHAHIN ADAM (BA)
Entity Type:Individual
Prefix:
First Name:SHAHIN
Middle Name:ADAM
Last Name:BAVARSAD
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10154 ASHFORD ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3001
Mailing Address - Country:US
Mailing Address - Phone:562-507-6861
Mailing Address - Fax:
Practice Address - Street 1:6809 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4221
Practice Address - Country:US
Practice Address - Phone:866-823-4283
Practice Address - Fax:475-235-3169
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician