Provider Demographics
NPI:1982092763
Name:KHATIBLOO, SHOURA (MA PHD)
Entity type:Individual
Prefix:DR
First Name:SHOURA
Middle Name:
Last Name:KHATIBLOO
Suffix:
Gender:F
Credentials:MA PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SPECTRUM CENTER DR STE 900
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4974
Mailing Address - Country:US
Mailing Address - Phone:714-457-6370
Mailing Address - Fax:714-364-0071
Practice Address - Street 1:100 SPECTRUM CENTER DR STE 900
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-4974
Practice Address - Country:US
Practice Address - Phone:714-457-6370
Practice Address - Fax:949-502-4725
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst