Provider Demographics
NPI:1699043232
Name:KHORASANI, MYRIAD R (LICSW)
Entity Type:Individual
Prefix:
First Name:MYRIAD
Middle Name:R
Last Name:KHORASANI
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:857-307-0897
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-10
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY084611-11041C0700X
MA1211621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical