Provider Demographics
NPI:1982092763
Name:KHATIBLOO, SHOURA (MA)
Entity Type:Individual
Prefix:MRS
First Name:SHOURA
Middle Name:
Last Name:KHATIBLOO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CALLE SALTAMONTES
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7004
Mailing Address - Country:US
Mailing Address - Phone:714-457-6370
Mailing Address - Fax:714-364-0071
Practice Address - Street 1:4199 CAMPUS DR
Practice Address - Street 2:SUITE 300
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-4684
Practice Address - Country:US
Practice Address - Phone:949-502-4721
Practice Address - Fax:949-502-4725
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst