Provider Demographics
NPI:1750639548
Name:EIVAZZADEH, ROULAN (ACSW)
Entity Type:Individual
Prefix:MR
First Name:ROULAN
Middle Name:
Last Name:EIVAZZADEH
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W AVENUE J STE C
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-3443
Mailing Address - Country:US
Mailing Address - Phone:661-949-0131
Mailing Address - Fax:661-729-8912
Practice Address - Street 1:921 W AVENUE J STE C
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3443
Practice Address - Country:US
Practice Address - Phone:661-949-0131
Practice Address - Fax:661-729-8912
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW34696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health