Healthcare Provider Details

I. General information

NPI: 1174371413
Provider Name (Legal Business Name): NAGHMEH MOADAB PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 PEACHTREE RD NW
ATLANTA GA
30309-1465
US

IV. Provider business mailing address

2144 PEACHTREE RD NW APT 505
ATLANTA GA
30309-1638
US

V. Phone/Fax

Practice location:
  • Phone: 404-603-5062
  • Fax:
Mailing address:
  • Phone: 804-731-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number6301019344
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: