Healthcare Provider Details

I. General information

NPI: 1275799298
Provider Name (Legal Business Name): SOHA HEIDARI GONZALEZ PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2008
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 COCHRAN ST # 1009
SIMI VALLEY CA
93065-0700
US

IV. Provider business mailing address

2880 COCHRAN ST # 1009
SIMI VALLEY CA
93065-0700
US

V. Phone/Fax

Practice location:
  • Phone: 818-971-9194
  • Fax: 855-270-9495
Mailing address:
  • Phone: 818-971-9194
  • Fax: 855-270-9495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27712
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: