Provider Demographics
NPI:1558434035
Name:KHAZENI, KIM (MSW)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:
Last Name:KHAZENI
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14751 PLAZA DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2702
Mailing Address - Country:US
Mailing Address - Phone:949-509-3041
Mailing Address - Fax:714-544-4472
Practice Address - Street 1:14751 PLAZA DR
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2702
Practice Address - Country:US
Practice Address - Phone:949-509-3041
Practice Address - Fax:714-544-4472
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALS123351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical