Provider Demographics
NPI:1083973861
Name:KHAN, IMAN LYNN (MS)
Entity Type:Individual
Prefix:
First Name:IMAN
Middle Name:LYNN
Last Name:KHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 30TH CT
Mailing Address - Street 2:UNIT F
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:414-745-4722
Mailing Address - Fax:
Practice Address - Street 1:8800 S 102ND ST
Practice Address - Street 2:103
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-7712
Practice Address - Country:US
Practice Address - Phone:414-858-1014
Practice Address - Fax:414-858-1017
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4771-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional