Provider Demographics
NPI:1265782668
Name:ABDELLI, AMIR
Entity type:Individual
Prefix:MR
First Name:AMIR
Middle Name:
Last Name:ABDELLI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 POTRERO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3594
Mailing Address - Country:US
Mailing Address - Phone:628-206-8426
Mailing Address - Fax:
Practice Address - Street 1:1525 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2591
Practice Address - Country:US
Practice Address - Phone:414-966-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2025-04-07
Deactivation Date:2018-03-23
Deactivation Code:
Reactivation Date:2018-04-11
Provider Licenses
StateLicense IDTaxonomies
CAA1643652084P0800X
WI773762084P0800X
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100212954Medicaid