Healthcare Provider Details

I. General information

NPI: 1043869969
Provider Name (Legal Business Name): JOHN CYRUS GHADAR MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 11TH ST
SAN FRANCISCO CA
94103-3732
US

IV. Provider business mailing address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

V. Phone/Fax

Practice location:
  • Phone: 415-355-0311
  • Fax: 415-431-1813
Mailing address:
  • Phone: 323-380-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number97750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: