=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063564094
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN H KHANJIAN L.P.C., & L.C.A.D.C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 01/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1172 E RIDGEWOOD AVE STE 4
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-857-5909
-----------------------------------------------------
Fax | 201-632-6454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 TENAFLY RD UNIT 441
-----------------------------------------------------
City | TENAFLY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07670-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-857-5909
-----------------------------------------------------
Fax | 201-632-6454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 37LC00126800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 37PC00197500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------