Provider Demographics
NPI:1053204016
Name:MAHDAVI, SAMAR
Entity type:Individual
Prefix:
First Name:SAMAR
Middle Name:
Last Name: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 1:17 COPPS HILL ST
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4705
Mailing Address - Country:US
Mailing Address - Phone:949-973-2552
Mailing Address - Fax:
Practice Address - Street 1:23276 S POINTE DR STE 105
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1430
Practice Address - Country:US
Practice Address - Phone:949-735-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA154399106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist