Provider Demographics
NPI:1023463874
Name:BARDAKJIAN, SHANT (LMFT108744)
Entity type:Individual
Prefix:MR
First Name:SHANT
Middle Name:
Last Name:BARDAKJIAN
Suffix:
Gender:M
Credentials:LMFT108744
Other - Prefix:MR
Other - First Name:SHANT
Other - Middle Name:GREG
Other - Last Name:BARDAKJIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT108744
Mailing Address - Street 1:237 N CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3526
Mailing Address - Country:US
Mailing Address - Phone:626-684-2325
Mailing Address - Fax:
Practice Address - Street 1:237 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2531
Practice Address - Country:US
Practice Address - Phone:818-547-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108744106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist