=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497203939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSS CULTURAL EXPRESSIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2016
-----------------------------------------------------
Last Update Date | 01/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17530 VENTURA BLVD # 203
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-3818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-860-1223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17514 VENTURA BLVD #101
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-860-1223
-----------------------------------------------------
Fax | 818-960-0274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. MASTANEH GOLIAN MOGHADAM
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 818-933-1148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LCS 23095
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------