Provider Demographics
NPI:1568572048
Name:TAVAKOLI, MANOUCHER X (PHD)
Entity Type:Individual
Prefix:DR
First Name:MANOUCHER
Middle Name:X
Last Name:TAVAKOLI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55262
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91413-0262
Mailing Address - Country:US
Mailing Address - Phone:818-981-1612
Mailing Address - Fax:866-656-3811
Practice Address - Street 1:18305 SHERMAN WAY
Practice Address - Street 2:#29
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4425
Practice Address - Country:US
Practice Address - Phone:818-981-1612
Practice Address - Fax:866-656-3811
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11289103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA247514OtherMHN PIN #
CA247514OtherMHN PIN #