Provider Demographics
NPI:1447853445
Name:FAZEL, MAHDIYA
Entity type:Individual
Prefix:
First Name:MAHDIYA
Middle Name:
Last Name:FAZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8025 PARSONS BLVD APT A23
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1039
Mailing Address - Country:US
Mailing Address - Phone:407-227-3889
Mailing Address - Fax:
Practice Address - Street 1:465 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4800
Practice Address - Country:US
Practice Address - Phone:212-420-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist