Provider Demographics
NPI:1255847414
Name:BEHROUZIAN, KIMYA
Entity Type:Individual
Prefix:
First Name:KIMYA
Middle Name:
Last Name:BEHROUZIAN
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 1:1400 VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2612
Mailing Address - Country:US
Mailing Address - Phone:650-299-2000
Mailing Address - Fax:
Practice Address - Street 1:1400 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2612
Practice Address - Country:US
Practice Address - Phone:650-299-4736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2023-04-06
Deactivation Date:2020-02-24
Deactivation Code:
Reactivation Date:2022-03-17
Provider Licenses
StateLicense IDTaxonomies
CA33393103T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOther390200000X