Provider Demographics
NPI:1790299469
Name:SHAHRAM, SHABNAM (MA)
Entity type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:SHAHRAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17862 17TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2170
Mailing Address - Country:US
Mailing Address - Phone:714-661-5393
Mailing Address - Fax:
Practice Address - Street 1:17862 17TH ST STE 107
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2170
Practice Address - Country:US
Practice Address - Phone:714-661-5393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT123679106H00000X
CA123679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist