Healthcare Provider Details

I. General information

NPI: 1225744923
Provider Name (Legal Business Name): ANI KIRAKOSYAN I LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E BROADWAY STE 301A
GLENDALE CA
91205-1008
US

IV. Provider business mailing address

225 E BROADWAY STE 301A
GLENDALE CA
91205-1008
US

V. Phone/Fax

Practice location:
  • Phone: 818-612-5588
  • Fax:
Mailing address:
  • Phone: 818-612-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number100264
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number100264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: