MEDICARE: DR. SANAM ABRISHAMI

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	PSY26105	CA

General Provider Information

NPI Number	:	1861622276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANAM ABRISHAMI

Provider Business Mailing Address
First Line	:	1171 S ROBERTSON BLVD # 104
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1403
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11965 VENICE BLVD STE 202
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-3954
Country	:	US
Telephone Number	:	818-896-1161
Fax Number	:

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

Provider Enumeration Date	:	07/20/2009
Last Update Date	:	06/18/2015

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