Provider Demographics
NPI:1194322859
Name:AKHAVIZADEGAN, SHIVA
Entity type:Individual
Prefix:
First Name:SHIVA
Middle Name:
Last Name:AKHAVIZADEGAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10981 SAN DIEGO MISSION RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-2448
Mailing Address - Country:US
Mailing Address - Phone:619-889-2259
Mailing Address - Fax:
Practice Address - Street 1:1963 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2394
Practice Address - Country:US
Practice Address - Phone:196-233-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health