Healthcare Provider Details

I. General information

NPI: 1558962324
Provider Name (Legal Business Name): MARJANEH-MARCIA KHALITCHI-ALAVI PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARCIA K ALAVI PSYD

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 WILSHIRE BLVD #230
LOS ANGELES CA
90025
US

IV. Provider business mailing address

16221 QUEMADA ROAD
ENCINO CA
91436
US

V. Phone/Fax

Practice location:
  • Phone: 818-257-2007
  • Fax:
Mailing address:
  • Phone: 818-257-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: