Healthcare Provider Details

I. General information

NPI: 1134809437
Provider Name (Legal Business Name): MOJDEH SUSAN ESLAMI ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 05/13/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 HOWARD WAY STE 150
COSTA MESA CA
92626-1496
US

IV. Provider business mailing address

3400 AVENUE OF THE ARTS APT H414
COSTA MESA CA
92626-7183
US

V. Phone/Fax

Practice location:
  • Phone: 949-646-9227
  • Fax: 949-646-9191
Mailing address:
  • Phone: 949-202-9471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number105496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: