Provider Demographics
NPI:1538773643
Name:KHDAIER, ATHRA
Entity type:Individual
Prefix:
First Name:ATHRA
Middle Name:
Last Name:KHDAIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10873 W DEVONSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5760
Mailing Address - Country:US
Mailing Address - Phone:480-370-1745
Mailing Address - Fax:
Practice Address - Street 1:10873 W DEVONSHIRE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5760
Practice Address - Country:US
Practice Address - Phone:480-370-1745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst