Healthcare Provider Details

I. General information

NPI: 1043031073
Provider Name (Legal Business Name): BAHAREH MAHDAVI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 VILLAGE CREEK DR STE 100
PLANO TX
75093-4430
US

IV. Provider business mailing address

5723 HUMMINGBIRD LN
FAIRVIEW TX
75069-6843
US

V. Phone/Fax

Practice location:
  • Phone: 972-913-4738
  • Fax:
Mailing address:
  • Phone: 972-913-4738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number96233
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: