Provider Demographics
NPI:1316390065
Name:KETABIAN, REANNON MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:REANNON
Middle Name:MARIE
Last Name:KETABIAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:REANNON
Other - Middle Name:MARIE
Other - Last Name:KERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 805
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-0805
Mailing Address - Country:US
Mailing Address - Phone:858-829-8206
Mailing Address - Fax:
Practice Address - Street 1:10556 OLD CASTLE RD
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-5609
Practice Address - Country:US
Practice Address - Phone:831-239-1566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93397106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist