Provider Demographics
NPI:1215956404
Name:SHEHNIYILAGH, ESHAGH (PHD)
Entity type:Individual
Prefix:DR
First Name:ESHAGH
Middle Name:
Last Name:SHEHNIYILAGH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 SW 86TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-1484
Mailing Address - Country:US
Mailing Address - Phone:954-704-0610
Mailing Address - Fax:954-704-0610
Practice Address - Street 1:300 S PINE ISLAND RD STE 220
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2620
Practice Address - Country:US
Practice Address - Phone:954-243-3424
Practice Address - Fax:954-704-0610
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6614103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54834Medicare ID - Type UnspecifiedPROVIDER #