Basic Information
| Provider Information | |||||||||
| NPI: | 1114298361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GHEYASZADA | ||||||||
| FirstName: | NURGES | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40965 GRIMMER BLVD | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103646437 | ||||||||
| FaxNumber: | 5105694589 | ||||||||
| Practice Location | |||||||||
| Address1: | 40965 GRIMMER BLVD | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945382846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106577425 | ||||||||
| FaxNumber: | 5105694589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2012 | ||||||||
| LastUpdateDate: | 05/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 172V00000X | N | Other Service Providers | Community Health Worker | 106H00000X | 99272 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.