Provider Demographics
NPI:1881014991
Name:MANSOORY, MAHJUBA
Entity Type:Individual
Prefix:
First Name:MAHJUBA
Middle Name:
Last Name:MANSOORY
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 1:901 N PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2162
Mailing Address - Country:US
Mailing Address - Phone:310-316-1610
Mailing Address - Fax:626-403-0016
Practice Address - Street 1:901 N PACIFIC COAST HWY STE 200A
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-7702
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:626-403-0016
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67870106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist