Provider Demographics
NPI:1861523631
Name:KHADIVI, ALI (PHD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:KHADIVI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 101ST ST
Mailing Address - Street 2:PH-10
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5059
Mailing Address - Country:US
Mailing Address - Phone:212-662-4704
Mailing Address - Fax:212-662-4704
Practice Address - Street 1:1276 FULTON AVE
Practice Address - Street 2:4 SOUTH
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-3402
Practice Address - Country:US
Practice Address - Phone:718-901-8889
Practice Address - Fax:718-466-6060
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011060-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical