Provider Demographics
NPI:1811575111
Name:TERZYAN, AGAVNI
Entity Type:Individual
Prefix:
First Name:AGAVNI
Middle Name:
Last Name:TERZYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10526 DUBNOFF WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3921
Mailing Address - Country:US
Mailing Address - Phone:818-755-4950
Mailing Address - Fax:818-752-0783
Practice Address - Street 1:1069 E SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91501-1509
Practice Address - Country:US
Practice Address - Phone:818-237-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL