Provider Demographics
NPI:1194891234
Name:REZAI, FARIDEH H (PHD)
Entity type:Individual
Prefix:MS
First Name:FARIDEH
Middle Name:H
Last Name:REZAI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5737 TRINITY PLACE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120
Mailing Address - Country:US
Mailing Address - Phone:619-265-8383
Mailing Address - Fax:951-652-0308
Practice Address - Street 1:6645 ALVARADO RD #255
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120
Practice Address - Country:US
Practice Address - Phone:619-265-8383
Practice Address - Fax:951-652-0308
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X
CAPSY98990103T00000X
CAPSY9899103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0098990Medicaid
CA0009899Medicaid
CACP9899Medicare ID - Type Unspecified