Provider Demographics
NPI:1689318404
Name:SEYEDI-REZVANI, SADAT LEILA AZADEH
Entity Type:Individual
Prefix:
First Name:SADAT LEILA
Middle Name:AZADEH
Last Name:SEYEDI-REZVANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEILA
Other - Middle Name:AZADEH
Other - Last Name:REZVANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9387 PRADERA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1845
Mailing Address - Country:US
Mailing Address - Phone:909-610-0343
Mailing Address - Fax:
Practice Address - Street 1:3333 CONCOURS STE 4102
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-6564
Practice Address - Country:US
Practice Address - Phone:909-240-1764
Practice Address - Fax:909-259-2369
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician