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General NPI Number Information
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NPI Number | 1508116518
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Entity Type | Individual
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Provider Name | SIAMAK EHTESHAMZADEH PSYD
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Gender | Male
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Dates
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Enumeration Date | 09/17/2012
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Last Update Date | 04/12/2025
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Provider Practice Location Address
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Address Line | 25320 LURIN AVE
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City | MORENO VALLEY
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State | CA
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Zip | 92551-2405
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Country | US
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Telephone | 951-217-9363
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8461
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City | MORENO VALLEY
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State | CA
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Zip | 92552-8461
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Country | US
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Telephone | 951-217-9363
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSB37425
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TF0000X
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Taxonomy Name | Family Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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