Provider Demographics
NPI:1205127446
Name:MIRZADEH, ODELIA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ODELIA
Middle Name:
Last Name:MIRZADEH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8665 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 412
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2975
Mailing Address - Country:US
Mailing Address - Phone:310-659-9511
Mailing Address - Fax:
Practice Address - Street 1:8665 WILSHIRE BLVD
Practice Address - Street 2:SUITE 412
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2975
Practice Address - Country:US
Practice Address - Phone:310-659-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15669235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist