Provider Demographics
NPI:1871276774
Name:PEAK BRAIN CLINIC
Entity type:Organization
Organization Name:PEAK BRAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUDARZI
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-853-2939
Mailing Address - Street 1:4111 E VALLEY AUTO DRIVE
Mailing Address - Street 2:SUITE 101, RM9
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-788-7254
Mailing Address - Fax:
Practice Address - Street 1:4111 E VALLEY AUTO DRIVE
Practice Address - Street 2:SUITE 101, RM9
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-788-7254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty