Basic Information
| Provider Information | |||||||||
| NPI: | 1720203458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REZAPOUR | ||||||||
| FirstName: | MEHRNOOSH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24040 KILLION ST | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913675726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109851160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1540 E COLORADO ST | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912051514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182447257 | ||||||||
| FaxNumber: | 8182435431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7283 | 05 | CA | MEDICAID |