Healthcare Provider Details

I. General information

NPI: 1437287257
Provider Name (Legal Business Name): MITRA - SHAHBANI-YEGANEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2183 FAIRVIEW RD STE 100
COSTA MESA CA
92627-5671
US

IV. Provider business mailing address

2121 E 1ST ST UNIT 203
LONG BEACH CA
90803-2403
US

V. Phone/Fax

Practice location:
  • Phone: 949-515-5440
  • Fax: 949-515-5444
Mailing address:
  • Phone: 562-434-1126
  • Fax: 562-434-1126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: