MEDICARE: A GHEYTANCHI PHD, A PSYCHOLOGICAL CORPORATION

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
1	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1538477800	OTHER	CA	NPI

General Provider Information

NPI Number	:	1265138630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A GHEYTANCHI PHD, A PSYCHOLOGICAL CORPORATION

Provider Business Mailing Address
First Line	:	10384 HOLMAN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-5351
Country	:	US
Telephone Number	:	323-270-1083
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 OCEAN PARK BLVD STE 110
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90405-3223
Country	:	US
Telephone Number	:	310-709-3073
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ANAHITA GHEYTANCHI
Credential	:	PHD
Telephone Number	:	310-709-3073

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	02/06/2023

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