Provider Demographics
NPI:1700277902
Name:AZIZI, SOUDABEH
Entity Type:Individual
Prefix:
First Name:SOUDABEH
Middle Name:
Last Name:AZIZI
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 1:661 LIVE OAK AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4863
Mailing Address - Country:US
Mailing Address - Phone:650-857-1477
Mailing Address - Fax:650-857-1477
Practice Address - Street 1:661 LIVE OAK AVE STE 5
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4863
Practice Address - Country:US
Practice Address - Phone:650-857-1477
Practice Address - Fax:650-857-1477
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42631106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist