Healthcare Provider Details

I. General information

NPI: 1912041484
Provider Name (Legal Business Name): FARIBA KEZEL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FARIBA EBRAHIM KHAN KHEZEL

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4199 CAMPUS DR SUITE 550
IRVINE CA
92612-4696
US

IV. Provider business mailing address

4199 CAMPUS DR SUITE 550
IRVINE CA
92612-4696
US

V. Phone/Fax

Practice location:
  • Phone: 714-490-4965
  • Fax: 949-509-6599
Mailing address:
  • Phone: 714-490-4965
  • Fax: 949-509-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY20295
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY20295
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY20295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: