Provider Demographics
NPI:1154638450
Name:DEPTH PSYCHOTHERAPY CENTER A PROFESSIONAL PSYCHOLOGICAL CORPORA
Entity type:Organization
Organization Name:DEPTH PSYCHOTHERAPY CENTER A PROFESSIONAL PSYCHOLOGICAL CORPORA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHDAVI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-422-4488
Mailing Address - Street 1:750 TERRADO PLZ
Mailing Address - Street 2:SUITE 40
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-332-0556
Mailing Address - Fax:
Practice Address - Street 1:4199 CAMPUS DR.
Practice Address - Street 2:SUITE 550
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612
Practice Address - Country:US
Practice Address - Phone:949-422-4488
Practice Address - Fax:949-640-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21506103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty