Provider Demographics
NPI:1730666876
Name:SOORMA, MARIYAM
Entity type:Individual
Prefix:
First Name:MARIYAM
Middle Name:
Last Name:SOORMA
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 1:8750 TOPANGA CANYON BLVD APT 21
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-2484
Mailing Address - Country:US
Mailing Address - Phone:818-334-7637
Mailing Address - Fax:
Practice Address - Street 1:8750 TOPANGA CANYON BLVD APT 21
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91304-2484
Practice Address - Country:US
Practice Address - Phone:818-334-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-22
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA119856101YM0800X
CA147224106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health