Provider Demographics
NPI:1215404439
Name:AFSARIFARD, KAYVON ADAM
Entity type:Individual
Prefix:MR
First Name:KAYVON
Middle Name:ADAM
Last Name:AFSARIFARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 CAMINO DEL REY
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-4601
Mailing Address - Country:US
Mailing Address - Phone:440-279-3525
Mailing Address - Fax:
Practice Address - Street 1:6620 CAMINO DEL REY
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-4601
Practice Address - Country:US
Practice Address - Phone:440-279-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108203101YM0800X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health