Provider Demographics
NPI:1902437585
Name:HAROUN MAHDAVI, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:HAROUN MAHDAVI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504-2545
Mailing Address - Country:US
Mailing Address - Phone:570-904-7363
Mailing Address - Fax:570-348-4079
Practice Address - Street 1:260 DALEVILLE HWY STE 106
Practice Address - Street 2:
Practice Address - City:COVINGTON TWP
Practice Address - State:PA
Practice Address - Zip Code:18444-7951
Practice Address - Country:US
Practice Address - Phone:570-904-7363
Practice Address - Fax:570-348-4079
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional