Healthcare Provider Details

I. General information

NPI: 1265985758
Provider Name (Legal Business Name): AIDIN TAJBAKHSH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10717 CAMINO RUIZ STE 207
SAN DIEGO CA
92126-2364
US

IV. Provider business mailing address

10717 CAMINO RUIZ STE 207
SAN DIEGO CA
92126-2364
US

V. Phone/Fax

Practice location:
  • Phone: 858-695-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: