Provider Demographics
NPI:1942796305
Name:YADEGAR, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:YADEGAR
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 1:1158 26TH ST STE 492
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5140 GOLDLEAF CIR
Practice Address - Street 2:#250
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90056
Practice Address - Country:US
Practice Address - Phone:323-391-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022940103TC0700X
CA30287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical