Basic Information
| Provider Information | |||||||||
| NPI: | 1104256767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAZELI | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTANO | ||||||||
| OtherFirstName: | EMMA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 27240 TURNBERRY LANE | ||||||||
| Address2: | STE 240 | ||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612547086 | ||||||||
| FaxNumber: | 6612547108 | ||||||||
| Practice Location | |||||||||
| Address1: | 27240 TURNBERRY LANE | ||||||||
| Address2: | STE 240 | ||||||||
| City: | VALENCIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612547086 | ||||||||
| FaxNumber: | 6612547108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2013 | ||||||||
| LastUpdateDate: | 11/19/2013 | ||||||||
| 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 | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.