Provider Demographics
NPI:1639642929
Name:MOHTASHAM, MANDANA (RBT)
Entity Type:Individual
Prefix:
First Name:MANDANA
Middle Name:
Last Name:MOHTASHAM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 N PERSHING DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-1446
Mailing Address - Country:US
Mailing Address - Phone:251-767-5501
Mailing Address - Fax:
Practice Address - Street 1:2201 N PERSHING DR APT 305
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-1473
Practice Address - Country:US
Practice Address - Phone:251-767-5501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician