Provider Demographics
NPI:1104924208
Name:SIMONIAN, STEPHAN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:
Last Name:SIMONIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 N BRAND BLVD
Mailing Address - Street 2:SUITE # 306
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-2511
Mailing Address - Country:US
Mailing Address - Phone:818-551-1118
Mailing Address - Fax:818-551-1955
Practice Address - Street 1:1141 N BRAND BLVD
Practice Address - Street 2:SUITE # 306
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202
Practice Address - Country:US
Practice Address - Phone:818-551-1118
Practice Address - Fax:818-551-1955
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50787101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C507870Medicaid
CAB97740Medicare UPIN
CAC50787Medicare ID - Type Unspecified