Provider Demographics
NPI:1780762658
Name:GHARADJEDAGHI, EHSAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:EHSAN
Middle Name:
Last Name:GHARADJEDAGHI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17900 SKY PARK CIR
Mailing Address - Street 2:103
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6436
Mailing Address - Country:US
Mailing Address - Phone:949-510-1321
Mailing Address - Fax:
Practice Address - Street 1:17900 SKY PARK CIR
Practice Address - Street 2:103
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6436
Practice Address - Country:US
Practice Address - Phone:949-510-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X, 103TF0000X, 103TP2701X
CAPSY25155103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy