Provider Demographics
NPI:1063747137
Name:GABICHVADZE, MINDIA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MINDIA
Middle Name:
Last Name:GABICHVADZE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9713 SANTA MONICA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4236
Mailing Address - Country:US
Mailing Address - Phone:310-564-5400
Mailing Address - Fax:844-654-2900
Practice Address - Street 1:9713 SANTA MONICA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4236
Practice Address - Country:US
Practice Address - Phone:310-564-5400
Practice Address - Fax:844-654-2900
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY34139103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1063747137Medicaid