Provider Demographics
NPI:1609287440
Name:TER-PETROSYAN, MARIAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:TER-PETROSYAN
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 1:1039 JUSTIN AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3616
Mailing Address - Country:US
Mailing Address - Phone:818-568-4185
Mailing Address - Fax:
Practice Address - Street 1:700 PARK AVENUE
Practice Address - Street 2:MCAR-410
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504
Practice Address - Country:US
Practice Address - Phone:757-451-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31182103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program