Healthcare Provider Details

I. General information

NPI: 1265138630
Provider Name (Legal Business Name): A GHEYTANCHI PHD, A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 OCEAN PARK BLVD STE 110
SANTA MONICA CA
90405-3223
US

IV. Provider business mailing address

10384 HOLMAN AVE
LOS ANGELES CA
90024-5351
US

V. Phone/Fax

Practice location:
  • Phone: 310-709-3073
  • Fax:
Mailing address:
  • Phone: 323-270-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ANAHITA GHEYTANCHI
Title or Position: OWNER
Credential: PHD
Phone: 310-709-3073