Provider Demographics
NPI:1548659642
Name:VAZIFDAR, ANITA
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:VAZIFDAR
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 1:95 N MARENGO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-4550
Mailing Address - Country:US
Mailing Address - Phone:626-585-8075
Mailing Address - Fax:
Practice Address - Street 1:95 N MARENGO AVE STE 100
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-4550
Practice Address - Country:US
Practice Address - Phone:626-585-8075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82869101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health