Provider Demographics
NPI:1225156003
Name:MANSOURI, BRANDON MICHELLE LALEH (MS)
Entity type:Individual
Prefix:MS
First Name:BRANDON
Middle Name:MICHELLE LALEH
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:BRANDY
Other - Middle Name:MICHELLE LAHLEH
Other - Last Name:MANSOURI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 8754
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-0754
Mailing Address - Country:US
Mailing Address - Phone:909-597-2226
Mailing Address - Fax:
Practice Address - Street 1:4344 LATHAM ST STE 110
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1773
Practice Address - Country:US
Practice Address - Phone:716-259-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 49234106H00000X
CA47648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47684OtherLMFT