Provider Demographics
NPI:1841519014
Name:KHOSHABA, SUHAM
Entity type:Individual
Prefix:
First Name:SUHAM
Middle Name:
Last Name:KHOSHABA
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 1:132 S COMMON ST
Mailing Address - Street 2:APT. 103
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-4582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 WHEELER ST
Practice Address - Street 2:SUITE 401
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-4416
Practice Address - Country:US
Practice Address - Phone:781-417-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor