MEDICARE: BAHAR MOHEBAN PSYD

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	PSY32421	CA

General Provider Information

NPI Number	:	1700368479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAHAR MOHEBAN PSYD

Provider Business Mailing Address
First Line	:	5665 WILSHIRE BLVD # 1033
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3710
Country	:	US
Telephone Number	:	707-872-7727
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 WILSHIRE BLVD # 1033
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3710
Country	:	US
Telephone Number	:	707-872-7727
Fax Number	:

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

Provider Enumeration Date	:	08/29/2018
Last Update Date	:	12/03/2021

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