Provider Demographics
NPI:1043247497
Name:KHORRAM, AVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:AVID
Middle Name:
Last Name:KHORRAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 GARDEN VIEW COURT
Mailing Address - Street 2:20
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-635-0044
Mailing Address - Fax:760-635-0044
Practice Address - Street 1:701 GARDEN VIEW COURT
Practice Address - Street 2:20
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024
Practice Address - Country:US
Practice Address - Phone:760-635-0044
Practice Address - Fax:760-635-0044
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14341103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP14341Medicare ID - Type UnspecifiedNHIC