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NPI Code Detail

MEDICARE: DR AZADEH GOLSHANI PSYCHOLOGIST PC

MEDICARE: DR AZADEH GOLSHANI PSYCHOLOGIST PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QR0405XSubstance Use Disorder Rehabilitation Clinic/CenterPSY28464
2261QM0850XAdult Mental Health Clinic/CenterPSY28464CA
3261QM0855XAdolescent and Children Mental Health Clinic/Center
4261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)PSY28464CA

General Provider Information

NPI Number : 1134658065
Entity Type Code : Organization
Provider Name (Legal Business Name) : DR AZADEH GOLSHANI PSYCHOLOGIST PC
Provider Business Mailing Address
First Line : 11045 MISSOURI AVE APT 203
Second Line :
City : LOS ANGELES
State : CA
Zip : 90025-5625
Country : US
Telephone Number : 310-927-9853
Fax Number :
Provider Business Practice Location Address
First Line : 3415 S SEPULVEDA BLVD STE 1100
Second Line :
City : LOS ANGELES
State : CA
Zip : 90034-7090
Country : US
Telephone Number : 310-927-9853
Fax Number :
Authorized Official
Title or Position : PSYCHOLOGIST
Name : AZADEH GOLSHANI
Credential : PSY.D
Telephone Number : 310-927-9853
Provider Enumeration Date : 06/05/2017
Last Update Date : 06/05/2017

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