Provider Demographics
NPI:1508303025
Name:KOOKLAN, FARIBA (MSLMFT)
Entity Type:Individual
Prefix:
First Name:FARIBA
Middle Name:
Last Name:KOOKLAN
Suffix:
Gender:F
Credentials:MSLMFT
Other - Prefix:
Other - First Name:FARIBA
Other - Middle Name:
Other - Last Name:KAMKAR FASSAIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS LMFT
Mailing Address - Street 1:17777 VENTURA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3738
Mailing Address - Country:US
Mailing Address - Phone:805-231-0854
Mailing Address - Fax:
Practice Address - Street 1:17777 VENTURA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3736
Practice Address - Country:US
Practice Address - Phone:818-908-1233
Practice Address - Fax:818-908-1234
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45702106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist