Healthcare Provider Details

I. General information

NPI: 1962624601
Provider Name (Legal Business Name): MEHDI EBRAHIMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 WEST STOCKER STREET #6
GLENDALE CA
91202-3523
US

IV. Provider business mailing address

512 W STOCKER ST #6
GLENDALE CA
91202-3523
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-9686
  • Fax:
Mailing address:
  • Phone: 818-241-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT8324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: