Provider Demographics
NPI:1780920066
Name:AZMOUDEH, AZADEH SOFIYA
Entity type:Individual
Prefix:
First Name:AZADEH
Middle Name:SOFIYA
Last Name:AZMOUDEH
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 1:25 VIA LUCCA
Mailing Address - Street 2:APT # J241
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-0600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29222 RANCHO VIEJO RD
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:949-429-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105096106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist