Healthcare Provider Details

I. General information

NPI: 1093064420
Provider Name (Legal Business Name): AZADEH GOLSHANI M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 LONG BEACH BLVD STE 700
LONG BEACH CA
90807-2000
US

IV. Provider business mailing address

711 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1831
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-5100
  • Fax:
Mailing address:
  • Phone: 213-385-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: