Provider Demographics
NPI:1821500075
Name:KERMANI, MITRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:KERMANI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MITRA
Other - Middle Name:
Other - Last Name:KERMANI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD (PSYCHOLOGIST)
Mailing Address - Street 1:29 TROPHY RDG
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-7715
Mailing Address - Country:US
Mailing Address - Phone:210-473-9250
Mailing Address - Fax:
Practice Address - Street 1:401 E SONTERRA BLVD STE 375
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4321
Practice Address - Country:US
Practice Address - Phone:210-473-9258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty