Basic Information
| Provider Information | |||||||||
| NPI: | 1437287257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAHBANI-YEGANEH | ||||||||
| FirstName: | MITRA | ||||||||
| MiddleName: | - | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 E 1ST ST UNIT 203 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908032403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624341126 | ||||||||
| FaxNumber: | 5624341126 | ||||||||
| Practice Location | |||||||||
| Address1: | 2183 FAIRVIEW RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926275671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495155440 | ||||||||
| FaxNumber: | 9495155444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.