Healthcare Provider Details

I. General information

NPI: 1235615543
Provider Name (Legal Business Name): LEILI ZARBAKHSH INTEGRATED INDIVIDUAL AND FAMILY THERAPY PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 CANYON CREST DR
RIVERSIDE CA
92507-7721
US

IV. Provider business mailing address

4642 NOELINE AVE
ENCINO CA
91436-2104
US

V. Phone/Fax

Practice location:
  • Phone: 747-447-2090
  • Fax: 747-444-4969
Mailing address:
  • Phone: 310-383-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: LEILI ZARBAKHSH
Title or Position: INCORPORATOR
Credential: LMFT, LEP
Phone: 747-447-2090