=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144848581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVISSA ILKHAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2020
-----------------------------------------------------
Last Update Date | 07/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7101 BAIRD AVE
-----------------------------------------------------
City | RESEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91335-4150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-342-5897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10201 MASON AVE UNIT 63
-----------------------------------------------------
City | CHATSWORTH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91311-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-994-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | R1395550620
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------