Provider Demographics
NPI:1760955397
Name:MADJLESSI, BIJAN (LMFT)
Entity Type:Individual
Prefix:
First Name:BIJAN
Middle Name:
Last Name:MADJLESSI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:1550 HOTEL CIR N STE 450
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2933
Practice Address - Country:US
Practice Address - Phone:619-692-1581
Practice Address - Fax:619-692-1588
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-07
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA116675106H00000X
CA103856101YM0800X
CALMFT116675106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty