Provider Demographics
NPI:1558408534
Name:BRAND PSYCHIATRIC MEDICAL GROUP
Entity Type:Organization
Organization Name:BRAND PSYCHIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHACHATRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-500-9708
Mailing Address - Street 1:138 N BRAND BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4614
Mailing Address - Country:US
Mailing Address - Phone:818-500-9708
Mailing Address - Fax:818-500-9709
Practice Address - Street 1:138 N BRAND BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4614
Practice Address - Country:US
Practice Address - Phone:818-500-9708
Practice Address - Fax:818-500-9709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66915174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty