Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | PSY26074 | CA |
Y | 103TC0700X | Clinical Psychologist | PSY26074 | CA |
N | 103TC1900X | Counseling Psychologist | PSY26074 | CA |
N | 103TF0000X | Family Psychologist | PSY26074 | CA |
N | 103TP2701X | Group Psychotherapist | PSY 26074 | CA |
NPI | 1083036537 |
---|---|
Provider Name | Dr. Kiyanoosh Shamlou |
First Address | Irvine, CA 92612-4684 |
Second Address | Irvine, CA 92612-4684 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2014 |
Last Update Date | 25/03/2020 |