Healthcare Provider Details

I. General information

NPI: 1285069039
Provider Name (Legal Business Name): MRS. AZITA KALANTAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRISTOL ST B-300
COSTA MESA CA
92626-5981
US

IV. Provider business mailing address

2900 BRISTOL ST B-300
COSTA MESA CA
92626-5981
US

V. Phone/Fax

Practice location:
  • Phone: 949-467-9213
  • Fax:
Mailing address:
  • Phone: 949-467-9213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number72249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: