Healthcare Provider Details

I. General information

NPI: 1609287440
Provider Name (Legal Business Name): MARIAM TER-PETROSYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17620 SHERMAN WAY STE 210
VAN NUYS CA
91406-3527
US

IV. Provider business mailing address

1621 MARION DR
GLENDALE CA
91205-3722
US

V. Phone/Fax

Practice location:
  • Phone: 818-568-4185
  • Fax:
Mailing address:
  • Phone: 818-568-4185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number31182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: