Provider Demographics
NPI:1174098974
Name:BOUSTANI, LADAN
Entity type:Individual
Prefix:DR
First Name:LADAN
Middle Name:
Last Name:BOUSTANI
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 1:12 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0711
Mailing Address - Country:US
Mailing Address - Phone:949-350-6416
Mailing Address - Fax:
Practice Address - Street 1:4685 MACARTHUR CT STE 340
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1855
Practice Address - Country:US
Practice Address - Phone:888-684-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27962103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY27962OtherCLINICAL PSYCHOLOGIST