Provider Demographics
NPI:1184959009
Name:PEZESHK, BANAFSHEH (PSYD)
Entity type:Individual
Prefix:DR
First Name:BANAFSHEH
Middle Name:
Last Name:PEZESHK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 POMERADO RD
Mailing Address - Street 2:SUITE B3
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2435
Mailing Address - Country:US
Mailing Address - Phone:760-607-6463
Mailing Address - Fax:760-607-3433
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE B3
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:760-607-6463
Practice Address - Fax:760-607-3433
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22843103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical