Provider Demographics
NPI:1619225489
Name:TEHRANI-RAD, SHERVIN (PSYD, MPH)
Entity type:Individual
Prefix:DR
First Name:SHERVIN
Middle Name:
Last Name:TEHRANI-RAD
Suffix:
Gender:M
Credentials:PSYD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3100
Mailing Address - Country:US
Mailing Address - Phone:269-408-1688
Mailing Address - Fax:
Practice Address - Street 1:415 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3100
Practice Address - Country:US
Practice Address - Phone:269-408-1688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2022-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33059103G00000X, 103T00000X, 103TC0700X
MI6301017839103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty