Provider Demographics
NPI:1720438625
Name:JAVANBAKHT, MARYAM FATHI (DPT)
Entity type:Individual
Prefix:MRS
First Name:MARYAM
Middle Name:FATHI
Last Name:JAVANBAKHT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:MARYAM
Other - Middle Name:
Other - Last Name:FATHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:12542 CHARLOMA DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2807
Mailing Address - Country:US
Mailing Address - Phone:310-355-8825
Mailing Address - Fax:
Practice Address - Street 1:544 S SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-355-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist