Provider Demographics
NPI:1558468595
Name:KHAKHAM, LARISSA (MSW, LMSW)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:KHAKHAM
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 SURF AVE
Mailing Address - Street 2:SUITE 11-S
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3550
Mailing Address - Country:US
Mailing Address - Phone:718-266-8117
Mailing Address - Fax:
Practice Address - Street 1:501 SURF AVE
Practice Address - Street 2:SUITE 11-S
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-3550
Practice Address - Country:US
Practice Address - Phone:718-266-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070933-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical