Healthcare Provider Details

I. General information

NPI: 1780775742
Provider Name (Legal Business Name): AUDREY KHATCHIKIAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N BRAND BLVD #507
GLENDALE CA
91203-2614
US

IV. Provider business mailing address

100 N BRAND BLVD #606
GLENDALE CA
91203-2614
US

V. Phone/Fax

Practice location:
  • Phone: 818-476-0066
  • Fax: 818-246-5532
Mailing address:
  • Phone: 818-476-0066
  • Fax: 818-246-5532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY18823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: