Provider Demographics
NPI:1043895915
Name:KHATRI, AYESHA
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:KHATRI
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 1:81 HAWTHORNE AVE APT SUITE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-5912
Mailing Address - Country:US
Mailing Address - Phone:631-568-1589
Mailing Address - Fax:
Practice Address - Street 1:81 HAWTHORNE AVE APT SUITE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-5912
Practice Address - Country:US
Practice Address - Phone:631-568-1589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY640-956-841103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst