Healthcare Provider Details

I. General information

NPI: 1306161583
Provider Name (Legal Business Name): GOLDEN STATE BEHAVIORAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E CHEVY CHASE DR SUITE 130
GLENDALE CA
91206-4197
US

IV. Provider business mailing address

1560 E CHEVY CHASE DR SUITE 130
GLENDALE CA
91206-4197
US

V. Phone/Fax

Practice location:
  • Phone: 818-240-0340
  • Fax: 818-545-7672
Mailing address:
  • Phone: 818-240-0340
  • Fax: 818-545-7672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG156084
License Number StateCA

VIII. Authorized Official

Name: DR. JAVAD RAZANI
Title or Position: PRESIDENT
Credential: MD
Phone: 310-471-7730