Basic Information
| Provider Information | |||||||||
| NPI: | 1255520177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALAVERDYAN | ||||||||
| FirstName: | MGER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ALAVERDYAN | ||||||||
| OtherFirstName: | MHER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 315 W ALAMEDA AVE # 7 | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915063352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182608710 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12450 VAN NUYS BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913311391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188961161 | ||||||||
| FaxNumber: | 8188965096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 10/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7068 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID |