Provider Demographics
NPI:1235224155
Name:KHORRAMI, SAM (PHD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:KHORRAMI
Suffix:
Gender:M
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:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:BRIELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08730-0269
Mailing Address - Country:US
Mailing Address - Phone:732-278-5615
Mailing Address - Fax:
Practice Address - Street 1:328 COMMONS WAY
Practice Address - Street 2:BUILDING C
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6428
Practice Address - Country:US
Practice Address - Phone:732-278-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S10041560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ083299Medicare ID - Type Unspecified