Provider Demographics
NPI:1356895734
Name:LEBOVIC, MISHGA VERA SOHRABI
Entity type:Individual
Prefix:
First Name:MISHGA
Middle Name:VERA SOHRABI
Last Name:LEBOVIC
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 1:3880 S BASCOM AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2600
Mailing Address - Country:US
Mailing Address - Phone:408-351-1044
Mailing Address - Fax:408-796-7477
Practice Address - Street 1:3880 S BASCOM AVE STE 115
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2600
Practice Address - Country:US
Practice Address - Phone:408-351-1044
Practice Address - Fax:408-796-7477
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3530786101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health