Provider Demographics
NPI:1073836300
Name:KHANIDEH, SHIRIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHIRIN
Middle Name:
Last Name:KHANIDEH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CORPORATE PARK STE 300
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5196
Mailing Address - Country:US
Mailing Address - Phone:949-870-7776
Mailing Address - Fax:
Practice Address - Street 1:8 CORPORATE PARK STE 300
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-5196
Practice Address - Country:US
Practice Address - Phone:949-870-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22528103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist