Provider Demographics
NPI:1801911151
Name:JANNATIPOUR, SHADAB BAHADOR (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHADAB
Middle Name:BAHADOR
Last Name:JANNATIPOUR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:SHADAB
Other - Middle Name:
Other - Last Name:BAHADOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:11620 WILSHIRE BLVD.
Mailing Address - Street 2:STE 450
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-445-2378
Mailing Address - Fax:
Practice Address - Street 1:23504 LYONS AVE STE 204
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2534
Practice Address - Country:US
Practice Address - Phone:661-286-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
CAPSY22662103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist