Healthcare Provider Details

I. General information

NPI: 1134658065
Provider Name (Legal Business Name): DR AZADEH GOLSHANI PSYCHOLOGIST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 S SEPULVEDA BLVD STE 1100
LOS ANGELES CA
90034-7090
US

IV. Provider business mailing address

11045 MISSOURI AVE APT 203
LOS ANGELES CA
90025-5625
US

V. Phone/Fax

Practice location:
  • Phone: 310-927-9853
  • Fax:
Mailing address:
  • Phone: 310-927-9853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberPSY28464
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPSY28464
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberPSY28464
License Number State

VIII. Authorized Official

Name: AZADEH GOLSHANI
Title or Position: PSYCHOLOGIST
Credential: PSY.D
Phone: 310-927-9853