Provider Demographics
NPI:1912501941
Name:MANDAVI BERENJI, ELHAM ELLIE
Entity Type:Individual
Prefix:
First Name:ELHAM
Middle Name:ELLIE
Last Name:MANDAVI BERENJI
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 1:121 BRUNNEN WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-2620
Mailing Address - Country:US
Mailing Address - Phone:210-717-6155
Mailing Address - Fax:
Practice Address - Street 1:121 BRUNNEN WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-2620
Practice Address - Country:US
Practice Address - Phone:210-717-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82942101YM0800X
TX15161101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health