=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316390065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REANNON MARIE KETABIAN LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2016
-----------------------------------------------------
Last Update Date | 07/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10556 OLD CASTLE RD
-----------------------------------------------------
City | VALLEY CENTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92082-5609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-239-1566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 805
-----------------------------------------------------
City | VALLEY CENTER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92082-0805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-829-8206
-----------------------------------------------------
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 | 93397
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------