MEDICARE: MAHTAB KAENI PSYD

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	103TC0700X	Clinical Psychologist	PSY24944	CA

General Provider Information

NPI Number	:	1578757399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAHTAB KAENI PSYD

Provider Business Mailing Address
First Line	:	4756 W HARVARD AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-8036
Country	:	US
Telephone Number	:	310-367-3207
Fax Number	:

Provider Business Practice Location Address
First Line	:	2440 W SHAW AVE STE 203
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93711-3300
Country	:	US
Telephone Number	:	559-930-5565
Fax Number	:

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

Provider Enumeration Date	:	09/05/2007
Last Update Date	:	01/10/2024

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