Provider Demographics
NPI:1659678068
Name:BAHADOR, ALBORZ
Entity Type:Individual
Prefix:
First Name:ALBORZ
Middle Name:
Last Name:BAHADOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72877 DINAH SHORE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2709
Mailing Address - Country:US
Mailing Address - Phone:310-383-3551
Mailing Address - Fax:213-402-2767
Practice Address - Street 1:72877 DINAH SHORE DR STE 103
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2709
Practice Address - Country:US
Practice Address - Phone:310-383-3551
Practice Address - Fax:213-402-2767
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY27236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical