MEDICARE: MRS. STEPHANIE MESDJIAN M.F.T.1

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	61620	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61620	OTHER	CA	BBS, MARRIAGE AND FAMILY THERAPIST-INTERN

General Provider Information

NPI Number	:	1124338348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE MESDJIAN M.F.T.1

Provider Business Mailing Address
First Line	:	2415 UNIVERSITY AVE STE 3
Second Line	:
City	:	EAST PALO ALTO
State	:	CA
Zip	:	94303-1148
Country	:	US
Telephone Number	:	650-363-4030
Fax Number	:

Provider Business Practice Location Address
First Line	:	2415 UNIVERSITY AVE STE 3
Second Line	:
City	:	EAST PALO ALTO
State	:	CA
Zip	:	94303-1148
Country	:	US
Telephone Number	:	650-363-4030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2010
Last Update Date	:	10/21/2010

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