Healthcare Provider Details

I. General information

NPI: 1699505156
Provider Name (Legal Business Name): MAHNAZ BAHAELOU AESTH, PMU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAHNAZ BAHAELOU AESTH, PMU

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11961 SANTA MONICA BOULEVARD
LOS ANGELES CA
90025-2748
US

IV. Provider business mailing address

11961 SANTA MONICA BOULEVARD
LOS ANGELES CA
90025-2748
US

V. Phone/Fax

Practice location:
  • Phone: 310-446-7878
  • Fax:
Mailing address:
  • Phone: 310-446-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: