Provider Demographics
NPI:1245077445
Name:MEHDAVI, MARWA SAHRA
Entity type:Individual
Prefix:
First Name:MARWA
Middle Name:SAHRA
Last Name:MEHDAVI
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 1:39510 PASEO PADRE PKWY STE 190
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4716
Mailing Address - Country:US
Mailing Address - Phone:510-403-5916
Mailing Address - Fax:
Practice Address - Street 1:39510 PASEO PADRE PKWY STE 190
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4716
Practice Address - Country:US
Practice Address - Phone:510-403-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician