Healthcare Provider Details

I. General information

NPI: 1487983144
Provider Name (Legal Business Name): SHAKEH BOGHARIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

7307 ENFIELD AVE
RESEDA CA
91335-3204
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax:
Mailing address:
  • Phone: 818-281-3738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW35322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: