Provider Demographics
NPI:1922408939
Name:KHEDEROO, ALIA (LMHC)
Entity Type:Individual
Prefix:
First Name:ALIA
Middle Name:
Last Name:KHEDEROO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 SE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6826
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:6000 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4615
Practice Address - Country:US
Practice Address - Phone:407-613-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22639101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health