Provider Demographics
NPI:1619170958
Name:ALDAVOUD, FAZLOLLAH (PHD)
Entity Type:Individual
Prefix:
First Name:FAZLOLLAH
Middle Name:
Last Name:ALDAVOUD
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 1:1460 TORREYANNA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-8724
Mailing Address - Country:US
Mailing Address - Phone:951-582-0895
Mailing Address - Fax:
Practice Address - Street 1:FIFTH AND WESTERN CALIFORNIA REHABILITATION CENTER
Practice Address - Street 2:DEPT OF CORRECTIONS STATE OF CALIFORNIA
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860
Practice Address - Country:US
Practice Address - Phone:951-737-2683
Practice Address - Fax:951-273-2974
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 23813106H00000X
CA25147174400000X
CAPSY 16601103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist