MEDICARE: DR. MANOUCHER X TAVAKOLI PH.D.

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	103TC0700X	Clinical Psychologist	PSY11289	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	247514	OTHER	CA	MHN PIN #

General Provider Information

NPI Number	:	1568572048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MANOUCHER X TAVAKOLI PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 55262
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91413-0262
Country	:	US
Telephone Number	:	818-981-1612
Fax Number	:	866-656-3811

Provider Business Practice Location Address
First Line	:	18305 SHERMAN WAY
Second Line	:	#29
City	:	RESEDA
State	:	CA
Zip	:	91335-4425
Country	:	US
Telephone Number	:	818-981-1612
Fax Number	:	866-656-3811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/09/2007

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