=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578226023
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHAYRAT ABDULLA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2021
-----------------------------------------------------
Last Update Date | 12/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3419 VALLE VERDE DR
-----------------------------------------------------
City | NAPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94558-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-721-2060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1224 COLOMA WAY
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-4601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-971-9822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------