Provider Demographics
NPI:1902956881
Name:AVANESOV, ALEXANDER YURYEVICH (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:YURYEVICH
Last Name:AVANESOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:SASHA
Other - Middle Name:
Other - Last Name:AVANESOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 471869
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94147-1869
Mailing Address - Country:US
Mailing Address - Phone:650-281-4072
Mailing Address - Fax:
Practice Address - Street 1:26 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3823
Practice Address - Country:US
Practice Address - Phone:650-367-9030
Practice Address - Fax:650-367-9032
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33518103TC0700X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical