Basic Information
| Provider Information | |||||||||
| NPI: | 1245880087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IZADI | ||||||||
| FirstName: | SHANETTE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3117 WILSON RD | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933045319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613244756 | ||||||||
| FaxNumber: | 6616172099 | ||||||||
| Practice Location | |||||||||
| Address1: | 44443 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617262630 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2019 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 97150 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.