Basic Information
| Provider Information | |||||||||
| NPI: | 1811151376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLESTAN | ||||||||
| FirstName: | BAHAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1753 E BROADWAY RD # 101-460 | ||||||||
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| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852822081 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 570 W BROWN RD | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852013227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2008 | ||||||||
| LastUpdateDate: | 04/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 324500000X | 42214 | AZ | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 2084P0800X | 42214 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.