Provider Demographics
NPI:1740935386
Name:KHAMOOSHIAN, BANAFSHEH BITA
Entity type:Individual
Prefix:
First Name:BANAFSHEH
Middle Name:BITA
Last Name:KHAMOOSHIAN
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 1:1682 LANGLEY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5620
Mailing Address - Country:US
Mailing Address - Phone:858-774-0963
Mailing Address - Fax:
Practice Address - Street 1:1682 LANGLEY AVE STE 1
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5620
Practice Address - Country:US
Practice Address - Phone:858-774-0963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT1305337101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor