Provider Demographics
NPI:1538907233
Name:THIAM, KHOREDIA
Entity type:Individual
Prefix:
First Name:KHOREDIA
Middle Name:
Last Name:THIAM
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 1:13354 MIDLOTHIAN TPKE STE 200
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4258
Mailing Address - Country:US
Mailing Address - Phone:804-277-9355
Mailing Address - Fax:
Practice Address - Street 1:13354 MIDLOTHIAN TPKE STE 200
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4258
Practice Address - Country:US
Practice Address - Phone:804-277-9355
Practice Address - Fax:804-210-2443
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health