Healthcare Provider Details

I. General information

NPI: 1578039608
Provider Name (Legal Business Name): ELIZABETH S VAHDATPOUR LMFT 124764
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2018
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27890 CLINTON KEITH RD STE D-352
MURRIETA CA
92562-8571
US

IV. Provider business mailing address

27890 CLINTON KEITH RD STE D-352
MURRIETA CA
92562-8571
US

V. Phone/Fax

Practice location:
  • Phone: 951-708-6516
  • Fax:
Mailing address:
  • Phone: 951-708-6516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number108583
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number108583
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number124764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: