Basic Information
| Provider Information | |||||||||
| NPI: | 1396264941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSTOFI | ||||||||
| FirstName: | SHIRIN | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 W. LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098262 | ||||||||
| FaxNumber: | 8552462329 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 W. LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098262 | ||||||||
| FaxNumber: | 8552462329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33247 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 103T00000X | 33247 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.