Provider Demographics
NPI:1922524701
Name:LAKE-KHOSRAVI, ANAHITA
Entity Type:Individual
Prefix:
First Name:ANAHITA
Middle Name:
Last Name:LAKE-KHOSRAVI
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 1:8354 E NORTHFIELD BLVD STE 3700
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-3131
Mailing Address - Country:US
Mailing Address - Phone:720-248-8633
Mailing Address - Fax:
Practice Address - Street 1:8354 E NORTHFIELD BLVD UNIT 3700
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3135
Practice Address - Country:US
Practice Address - Phone:720-248-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005846103TC0700X, 103T00000X
103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool