Provider Demographics
NPI:1194260083
Name:CHIHA, SHAHREZAD
Entity type:Individual
Prefix:
First Name:SHAHREZAD
Middle Name:
Last Name:CHIHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 MEDICAL CENTER CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-591-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-30
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA905181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor