Provider Demographics
NPI:1902380827
Name:BEHNOUD, MAHSAN
Entity Type:Individual
Prefix:
First Name:MAHSAN
Middle Name:
Last Name:BEHNOUD
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 1:8109 E BAILEY WAY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-2514
Mailing Address - Country:US
Mailing Address - Phone:714-299-1370
Mailing Address - Fax:
Practice Address - Street 1:17817 SANTIAGO BLVD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92861-4133
Practice Address - Country:US
Practice Address - Phone:714-299-1370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105879106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist