Provider Demographics
NPI:1699505156
Name:BAHAELOU, MAHNAZ (AESTH, PMU)
Entity type:Individual
Prefix:
First Name:MAHNAZ
Middle Name:
Last Name:BAHAELOU
Suffix:
Gender:F
Credentials:AESTH, PMU
Other - Prefix:MS
Other - First Name:MAHNAZ
Other - Middle Name:
Other - Last Name:BAHAELOU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AESTH, PMU
Mailing Address - Street 1:11961 SANTA MONICA BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2748
Mailing Address - Country:US
Mailing Address - Phone:310-446-7878
Mailing Address - Fax:
Practice Address - Street 1:11961 SANTA MONICA BOULEVARD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2748
Practice Address - Country:US
Practice Address - Phone:310-446-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist