Basic Information
| Provider Information | |||||||||
| NPI: | 1689041188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRZAD | ||||||||
| FirstName: | FERESHTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 800444 | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913800444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617292000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 44750 60TH ST W | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935367619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617292000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2015 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | PSY31397 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.