Provider Demographics
NPI:1639429996
Name:FAMILI, AZADEH (PHD)
Entity Type:Individual
Prefix:
First Name:AZADEH
Middle Name:
Last Name:FAMILI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E MEDA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2607
Mailing Address - Country:US
Mailing Address - Phone:626-253-3149
Mailing Address - Fax:626-857-9092
Practice Address - Street 1:150 E MEDA AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-2607
Practice Address - Country:US
Practice Address - Phone:626-253-3149
Practice Address - Fax:626-857-9092
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16456103TA0400X, 103TB0200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic