Provider Demographics
NPI:1144903493
Name:KHODADOUST, DARYA (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:DARYA
Middle Name:
Last Name:KHODADOUST
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47426 RIVERBANK FOREST PL
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-3169
Mailing Address - Country:US
Mailing Address - Phone:301-919-9492
Mailing Address - Fax:
Practice Address - Street 1:47426 RIVERBANK FOREST PL
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-3169
Practice Address - Country:US
Practice Address - Phone:301-919-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202011379235Z00000X
VA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202011379OtherLICENSE