=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407570393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDELWEISS INDIVIDUAL AND FAMILY THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2022
-----------------------------------------------------
Last Update Date | 06/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 QUAIL ST STE 206
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-229-0567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15615 ALTON PKWY STE 450
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-229-0567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSEDMARRIAGEANDFAMILYTHERAPIST
-----------------------------------------------------
Name | SABA MONTAZERIAN
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 949-229-0567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------