Healthcare Provider Details

I. General information

NPI: 1043247497
Provider Name (Legal Business Name): AVID KHORRAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GARDEN VIEW COURT 20
ENCINITAS CA
92024
US

IV. Provider business mailing address

701 GARDEN VIEW COURT 20
ENCINITAS CA
92024
US

V. Phone/Fax

Practice location:
  • Phone: 760-635-0044
  • Fax: 760-635-0044
Mailing address:
  • Phone: 760-635-0044
  • Fax: 760-635-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: