Provider Demographics
NPI:1376238816
Name:MOGHADAM, KIMIA
Entity Type:Individual
Prefix:MS
First Name:KIMIA
Middle Name:
Last Name:MOGHADAM
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 1:8 SPRUCE ST APT 20D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-5212
Mailing Address - Country:US
Mailing Address - Phone:347-479-4706
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 806
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8128
Practice Address - Country:US
Practice Address - Phone:646-449-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011406101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health