Provider Demographics
NPI:1679159321
Name:SOLTANI, KHOSROW R (LMHC, QS)
Entity type:Individual
Prefix:
First Name:KHOSROW
Middle Name:R
Last Name:SOLTANI
Suffix:
Gender:M
Credentials:LMHC, QS
Other - Prefix:MR
Other - First Name:KHOSROW
Other - Middle Name:R
Other - Last Name:SOLTANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:KHOSROW SOLTANI
Mailing Address - Street 1:14428 S MILITARY TRL UNIT B
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-3720
Mailing Address - Country:US
Mailing Address - Phone:561-543-8993
Mailing Address - Fax:
Practice Address - Street 1:14428 S MILITARY TRL UNIT B
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-3720
Practice Address - Country:US
Practice Address - Phone:561-543-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17507101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121883200Medicaid