Provider Demographics
NPI:1376716001
Name:KHAN, MARY BREARLEY (MFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BREARLEY
Last Name:KHAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BREARLEY
Other - Last Name:RAUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:738 S LOS ANGELES ST APT 401
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-2188
Mailing Address - Country:US
Mailing Address - Phone:310-487-1796
Mailing Address - Fax:310-487-1796
Practice Address - Street 1:19701 HAMILTON AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1352
Practice Address - Country:US
Practice Address - Phone:310-817-2177
Practice Address - Fax:310-817-2178
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49573106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist