Provider Demographics
NPI:1578017992
Name:MOTAMEDINIA, SHAHAB (PHD)
Entity type:Individual
Prefix:DR
First Name:SHAHAB
Middle Name:
Last Name:MOTAMEDINIA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 YONKERS AVE
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-3910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 W 73RD ST
Practice Address - Street 2:LOBBY SUITE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3006
Practice Address - Country:US
Practice Address - Phone:646-783-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021755103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist