Provider Demographics
NPI:1306106414
Name:GOOSHEH, MITRA (PHD, LAC, MSOM)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:GOOSHEH
Suffix:
Gender:F
Credentials:PHD, LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 S ROBERTSON BLVD
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1611
Mailing Address - Country:US
Mailing Address - Phone:310-657-0911
Mailing Address - Fax:
Practice Address - Street 1:918 S ROBERTSON BLVD
Practice Address - Street 2:#1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1611
Practice Address - Country:US
Practice Address - Phone:310-657-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist