Provider Demographics
NPI:1396057550
Name:MAHDAVI, AMIR (PHD)
Entity type:Individual
Prefix:DR
First Name:AMIR
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4403
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91308-4403
Mailing Address - Country:US
Mailing Address - Phone:818-917-7773
Mailing Address - Fax:
Practice Address - Street 1:15456 VENTURA BLVD STE 500
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3023
Practice Address - Country:US
Practice Address - Phone:818-917-7773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-04
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020974103TC0700X
CAPSY30512103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB322340Medicaid