Healthcare Provider Details

I. General information

NPI: 1841441029
Provider Name (Legal Business Name): BRANDON SHAPOOR PORSANDEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W BROADWAY
LONG BEACH CA
90802-4431
US

IV. Provider business mailing address

100 W BROADWAY
LONG BEACH CA
90802-4431
US

V. Phone/Fax

Practice location:
  • Phone: 562-243-6492
  • Fax:
Mailing address:
  • Phone: 562-243-6492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW70255
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberASW27600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: