Provider Demographics
NPI:1821339359
Name:SHAHROKH, BAHRAM EDWARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BAHRAM EDWARD
Middle Name:
Last Name:SHAHROKH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:B. EDWARD
Other - Middle Name:
Other - Last Name:SHAHROKH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:210 N PASS AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-3936
Mailing Address - Country:US
Mailing Address - Phone:805-764-1774
Mailing Address - Fax:
Practice Address - Street 1:210 N PASS AVE STE 101
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3936
Practice Address - Country:US
Practice Address - Phone:805-764-1774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33267103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical