Basic Information
| Provider Information | |||||||||
| NPI: | 1619100674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAHRAM | ||||||||
| FirstName: | NASTARAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6842 VAN NUYS BLVD | ||||||||
| Address2: | 5 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914054625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187570031 | ||||||||
| FaxNumber: | 8183746908 | ||||||||
| Practice Location | |||||||||
| Address1: | 5405 LINDLEY AVE | ||||||||
| Address2: | #320 | ||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913563742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187570031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2009 | ||||||||
| LastUpdateDate: | 08/27/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.