Provider Demographics
NPI:1437573631
Name:ESMAIL-POURGHOMI, PARVIN
Entity Type:Individual
Prefix:
First Name:PARVIN
Middle Name:
Last Name:ESMAIL-POURGHOMI
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 1:19 MCKENNA DR
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-1816
Mailing Address - Country:US
Mailing Address - Phone:603-897-0057
Mailing Address - Fax:
Practice Address - Street 1:15 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3923
Practice Address - Country:US
Practice Address - Phone:603-889-6147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH31142772417Medicaid