Provider Demographics
NPI:1568198349
Name:BOZORGI, EHSAN (AMFT, APCC)
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:BOZORGI
Suffix:
Gender:M
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 CADILLAC AVENUE
Mailing Address - Street 2:BUILDING O, SUITE 109
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626
Mailing Address - Country:US
Mailing Address - Phone:714-432-9856
Mailing Address - Fax:
Practice Address - Street 1:3505 CADILLAC AVENUE
Practice Address - Street 2:BUILDING O, SUITE 109
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-432-9856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT132184106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist