Provider Demographics
NPI:1609274976
Name:HEIDARI, PEGAH (MA)
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:HEIDARI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:PEGAH
Other - Middle Name:JENNIFER
Other - Last Name:HEIDARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, MFTI
Mailing Address - Street 1:43 CAPISTRANO
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2421
Mailing Address - Country:US
Mailing Address - Phone:949-300-3002
Mailing Address - Fax:
Practice Address - Street 1:3125 MYERS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5527
Practice Address - Country:US
Practice Address - Phone:951-358-6858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CA77504106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst