Healthcare Provider Details

I. General information

NPI: 1053336982
Provider Name (Legal Business Name): FARNAZ KHODADOOST-DEHGHI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 BREA BLVD STE 210
FULLERTON CA
92835-4128
US

IV. Provider business mailing address

1370 BREA BLVD STE 210
FULLERTON CA
92835-4128
US

V. Phone/Fax

Practice location:
  • Phone: 714-653-8805
  • Fax:
Mailing address:
  • Phone: 714-653-8805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY17403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: