Provider Demographics
NPI:1396116349
Name:JAVANFARD, SHIRA (MS, LCGC)
Entity type:Individual
Prefix:
First Name:SHIRA
Middle Name:
Last Name:JAVANFARD
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:SHIRA
Other - Middle Name:
Other - Last Name:KOHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LCGC
Mailing Address - Street 1:1034 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13640 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-3904
Practice Address - Country:US
Practice Address - Phone:818-375-2073
Practice Address - Fax:818-375-3635
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAGC000688170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program