=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194525519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERA KHANESHAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2025
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N CENTRAL AVE STE 340
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-4238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-649-2921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 E SANTA ANITA AVE APT 106
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91501-2985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-484-6671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | AMFT151961
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------