Healthcare Provider Details

I. General information

NPI: 1609532217
Provider Name (Legal Business Name): HANNAH M KHODDAM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HANNAH LYDEN

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1849 SAWTELLE BLVD STE 610
LOS ANGELES CA
90025-7013
US

IV. Provider business mailing address

9461 CHARLEVILLE BLVD # 921
BEVERLY HILLS CA
90212-3017
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-8788
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number32931
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: