Provider Demographics
NPI:1871771758
Name:GOSHTASBPOUR, FARANGIS (PHD)
Entity type:Individual
Prefix:
First Name:FARANGIS
Middle Name:
Last Name:GOSHTASBPOUR
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11304 HAWTHORNE DR
Practice Address - Street 2:STE 100
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9425
Practice Address - Country:US
Practice Address - Phone:704-545-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3324103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1871771758Medicaid
NCQ44571AMedicare PIN