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General NPI Number Information
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NPI Number | 1619170958
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Entity Type | Individual
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Provider Name | FAZLOLLAH ALDAVOUD PHD
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Gender | Male
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 07/25/2022
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Provider Practice Location Address
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Address Line | FIFTH AND WESTERN CALIFORNIA REHABILITATION CENTER DEPT OF CORRECTIONS STATE OF CALIFORNIA
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City | NORCO
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State | CA
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Zip | 92860
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Country | US
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Telephone | 951-737-2683
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Fax | 951-273-2974
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Provider Business Mailing Address
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Address Line | 1460 TORREYANNA CIRCLE
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City | CORONA
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State | CA
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Zip | 92882-8724
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Country | US
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Telephone | 951-582-0895
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC 23813
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25147
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY 16601
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License Number State | CA
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