Provider Demographics
NPI:1689374027
Name:SHAFA PSYCHIATRIC AND CONSULTING CENTER
Entity Type:Organization
Organization Name:SHAFA PSYCHIATRIC AND CONSULTING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHOSRAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:657-341-4422
Mailing Address - Street 1:1400 N KRAEMER BLVD UNIT 171
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92871-1408
Mailing Address - Country:US
Mailing Address - Phone:657-341-4422
Mailing Address - Fax:
Practice Address - Street 1:265 S RANDOLPH AVE STE 290
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5702
Practice Address - Country:US
Practice Address - Phone:657-341-4422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912384611OtherNPI