=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154785764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPY WITH ROXANNA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2016
-----------------------------------------------------
Last Update Date | 04/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16661 VENTURA BLVD #444
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-384-5527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16661 VENTURA BLVD #444
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-384-5527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ OWNER
-----------------------------------------------------
Name | ROXANNA YASHOUAFAR ABOUDI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 310-384-5527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | LCSW# 64161
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------