Provider Demographics
NPI:1013491034
Name:IRANNEJAD, FATHIEH (ETC)
Entity Type:Individual
Prefix:
First Name:FATHIEH
Middle Name:
Last Name:IRANNEJAD
Suffix:
Gender:F
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 SKYPARK DR STE 215
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5388
Mailing Address - Country:US
Mailing Address - Phone:310-753-7868
Mailing Address - Fax:
Practice Address - Street 1:2790 SKYPARK DR STE 215
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5388
Practice Address - Country:US
Practice Address - Phone:310-855-3990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94976106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAMFT94976OtherMENTAL HEALTH