Healthcare Provider Details

I. General information

NPI: 1245087204
Provider Name (Legal Business Name): ISAAC ALI MIRZADEGAN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST # 116B
SAN FRANCISCO CA
94121-1563
US

IV. Provider business mailing address

4150 CLEMENT ST (116B)
SAN FRANCISCO CA
94121-1563
US

V. Phone/Fax

Practice location:
  • Phone: 415-900-8196
  • Fax:
Mailing address:
  • Phone: 415-900-8196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number36078
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: