Healthcare Provider Details

I. General information

NPI: 1346124104
Provider Name (Legal Business Name): MRS. ANNET SAFARIAN GOODSIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N JACKSON ST
GLENDALE CA
91206-4380
US

IV. Provider business mailing address

PO BOX 12374
LA CRESCENTA CA
91224-5374
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-3111
  • Fax:
Mailing address:
  • Phone: 818-445-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-53571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: