Healthcare Provider Details

I. General information

NPI: 1043867310
Provider Name (Legal Business Name): LAVA JOSEPHINE KHURSHID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11665 AVENA PL STE 204
SAN DIEGO CA
92128-2428
US

IV. Provider business mailing address

11665 AVENA PL STE 204
SAN DIEGO CA
92128-2428
US

V. Phone/Fax

Practice location:
  • Phone: 858-200-8480
  • Fax:
Mailing address:
  • Phone: 858-200-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-92191
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: