Healthcare Provider Details

I. General information

NPI: 1205961349
Provider Name (Legal Business Name): TATEVIK KHACHATRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 CAMINO DE LA REINA STE 210
SAN DIEGO CA
92108-3104
US

IV. Provider business mailing address

2307 FENTON PKWY #107-239
SAN DIEGO CA
92108-4746
US

V. Phone/Fax

Practice location:
  • Phone: 619-206-5271
  • Fax: 619-795-3274
Mailing address:
  • Phone: 619-206-5271
  • Fax: 619-795-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPCC1335
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC1335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: