Provider Demographics
NPI:1285468603
Name:SADADIWALA, KHUSHBOO JITENDRA (PSYD)
Entity type:Individual
Prefix:
First Name:KHUSHBOO
Middle Name:JITENDRA
Last Name:SADADIWALA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 S BRENTWOOD BLVD APT 121
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1837
Mailing Address - Country:US
Mailing Address - Phone:267-357-3010
Mailing Address - Fax:
Practice Address - Street 1:11358 VAN CLEVE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-1131
Practice Address - Country:US
Practice Address - Phone:314-968-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00015546103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist