Provider Demographics
NPI:1710301478
Name:BAGHERI, ELHAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELHAM
Middle Name:
Last Name:BAGHERI
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 1:1758 CENTURY BLVD NE
Mailing Address - Street 2:STE B
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3392
Mailing Address - Country:US
Mailing Address - Phone:404-692-3073
Mailing Address - Fax:
Practice Address - Street 1:1758 CENTURY BLVD NE
Practice Address - Street 2:STE B
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3392
Practice Address - Country:US
Practice Address - Phone:404-692-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003760103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist