Provider Demographics
NPI:1578106100
Name:AHMADI, AZADEH
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:AHMADI
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 1:3477 LAKE AUSTIN BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-5560
Mailing Address - Country:US
Mailing Address - Phone:240-708-9508
Mailing Address - Fax:
Practice Address - Street 1:1717 W 10TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-3907
Practice Address - Country:US
Practice Address - Phone:512-472-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83106101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional