Provider Demographics
NPI:1689766974
Name:SAM KHORRAMI, PH.D., PC
Entity Type:Organization
Organization Name:SAM KHORRAMI, PH.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHORRAMI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:732-278-5615
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:BRIELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08730
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
Practice Address - Country:US
Practice Address - Phone:732-278-5615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S10041560103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ083299Medicare ID - Type Unspecified