Healthcare Provider Details

I. General information

NPI: 1366986788
Provider Name (Legal Business Name): KIRAN IDREES MALIK-ISLAM AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 S ANITA DR STE 102-104
ORANGE CA
92868-3355
US

IV. Provider business mailing address

4221 AVALON BOULEVARD
LOS ANGELES CA
90011
US

V. Phone/Fax

Practice location:
  • Phone: 714-410-3500
  • Fax:
Mailing address:
  • Phone: 323-233-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number132358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: