Healthcare Provider Details

I. General information

NPI: 1598229189
Provider Name (Legal Business Name): MAZHAR KHAN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N MAIN ST
ALGONQUIN IL
60102-2448
US

IV. Provider business mailing address

215 N MAIN ST
ALGONQUIN IL
60102-2448
US

V. Phone/Fax

Practice location:
  • Phone: 224-678-9033
  • Fax: 224-678-9493
Mailing address:
  • Phone: 224-678-9033
  • Fax: 224-678-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.004100
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: