Provider Demographics
NPI:1861622276
Name:ABRISHAMI, SANAM
Entity type:Individual
Prefix:DR
First Name:SANAM
Middle Name:
Last Name:ABRISHAMI
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 1:1171 S ROBERTSON BLVD # 104
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11965 VENICE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3954
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26105103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid