Provider Demographics
NPI:1639429640
Name:ELMI, MITRA H
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:H
Last Name:ELMI
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 1:149 STANFORD CT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1673
Mailing Address - Country:US
Mailing Address - Phone:949-424-3564
Mailing Address - Fax:
Practice Address - Street 1:4701 VON KARMAN AVE STE 328
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8136
Practice Address - Country:US
Practice Address - Phone:949-424-3564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58302106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist