Healthcare Provider Details

I. General information

NPI: 1588545685
Provider Name (Legal Business Name): MARAL AGHVINIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 W OLYMPIC BLVD STE 1270E
LOS ANGELES CA
90064-5053
US

IV. Provider business mailing address

396 31ST AVE
SAN FRANCISCO CA
94121-1707
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-4843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY35718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: