Provider Demographics
NPI:1023253564
Name:KHOSROABADI, ASAL LAURA
Entity type:Individual
Prefix:
First Name:ASAL
Middle Name:LAURA
Last Name:KHOSROABADI
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 1:945 CHALCEDONY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2503
Mailing Address - Country:US
Mailing Address - Phone:818-674-8540
Mailing Address - Fax:
Practice Address - Street 1:6655 ALVARADO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5208
Practice Address - Country:US
Practice Address - Phone:619-229-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA875661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health