Healthcare Provider Details

I. General information

NPI: 1235476318
Provider Name (Legal Business Name): WELL PSYCHE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 06/21/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15260 VENTURA BLVD STE 1200
SHERMAN OAKS CA
91403-5347
US

IV. Provider business mailing address

15260 VENTURA BLVD STE 1200
SHERMAN OAKS CA
91403-5347
US

V. Phone/Fax

Practice location:
  • Phone: 310-871-0670
  • Fax: 310-469-7845
Mailing address:
  • Phone: 310-871-0670
  • Fax: 310-469-7845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA92472
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA92472
License Number StateCA

VIII. Authorized Official

Name: ADEL MOSTAFAVI
Title or Position: CEO
Credential: MD
Phone: 949-400-2488