=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164514659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEHRNAZ MAHDAD PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 859 HARVARD ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-453-2810
-----------------------------------------------------
Fax | 310-828-5896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 859 HARVARD ST
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-453-2810
-----------------------------------------------------
Fax | 310-828-5896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------