Basic Information
Provider Information | |||||||||
NPI: | 1477989911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOUHIBIAN | ||||||||
FirstName: | ROMI | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | B.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4239 ARDEN WAY | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921031530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6196936643 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2555 E COLORADO BLVD | ||||||||
Address2: | SUITE 100 | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911076622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6265772261 | ||||||||
FaxNumber: | 6265772543 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2013 | ||||||||
LastUpdateDate: | 08/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 30135 | CA | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.