Provider Demographics
NPI:1114793601
Name:KEOSSEIAN, MARAL
Entity Type:Individual
Prefix:
First Name:MARAL
Middle Name:
Last Name:KEOSSEIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 RISA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2319
Mailing Address - Country:US
Mailing Address - Phone:818-823-6787
Mailing Address - Fax:
Practice Address - Street 1:2441 RISA DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-2319
Practice Address - Country:US
Practice Address - Phone:818-823-6787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142151106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist