Provider Demographics
NPI:1790511301
Name:EBRAHIMI, SHAHARZADE G
Entity type:Individual
Prefix:
First Name:SHAHARZADE
Middle Name:G
Last Name:EBRAHIMI
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 1:2412 KAYEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76209-2253
Mailing Address - Country:US
Mailing Address - Phone:940-594-5255
Mailing Address - Fax:
Practice Address - Street 1:1300 FULTON ST STE 402
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2661
Practice Address - Country:US
Practice Address - Phone:940-594-5255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1035021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical