Provider Demographics
NPI:1588849749
Name:EHTESHAMI-HUNT, ELHAM (MFT)
Entity Type:Individual
Prefix:
First Name:ELHAM
Middle Name:
Last Name:EHTESHAMI-HUNT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 FREDERICK ST STE I5 #317
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5235
Mailing Address - Country:US
Mailing Address - Phone:949-456-4265
Mailing Address - Fax:949-269-7957
Practice Address - Street 1:333 CORPORATE DR STE 260
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694-2180
Practice Address - Country:US
Practice Address - Phone:949-456-4265
Practice Address - Fax:949-269-7957
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43068106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1911PD0DMedicaid
CA1588849749Medicaid