=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497788558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAYAM GHASSEMLOU PH.D. , MFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 10/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8560 W SUNSET BLVD STE 500
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-2342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-801-2927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18177
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90209-4177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-801-2927
-----------------------------------------------------
Fax | 310-279-1090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT33893
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------