Healthcare Provider Details

I. General information

NPI: 1154580264
Provider Name (Legal Business Name): ROXANA VAHDAT LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 BALBOA BLVD STE 200
ENCINO CA
91316-1534
US

IV. Provider business mailing address

5535 BALBOA BLVD STE 200
ENCINO CA
91316-1534
US

V. Phone/Fax

Practice location:
  • Phone: 818-588-0752
  • Fax:
Mailing address:
  • Phone: 818-588-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: