Provider Demographics
NPI:1447732607
Name:LAZEMIZADEH, SHOHREH (MFT REGISTEREDINTERN)
Entity type:Individual
Prefix:
First Name:SHOHREH
Middle Name:
Last Name:LAZEMIZADEH
Suffix:
Gender:F
Credentials:MFT REGISTEREDINTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 EUREKA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3047
Mailing Address - Country:US
Mailing Address - Phone:916-426-2077
Mailing Address - Fax:
Practice Address - Street 1:1528 EUREKA RD STE 101
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3047
Practice Address - Country:US
Practice Address - Phone:916-426-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF106573106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist