Provider Demographics
NPI:1598229189
Name:KHAN, MAZHAR (PSYD)
Entity Type:Individual
Prefix:
First Name:MAZHAR
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2448
Mailing Address - Country:US
Mailing Address - Phone:224-678-9033
Mailing Address - Fax:224-678-9493
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-2448
Practice Address - Country:US
Practice Address - Phone:224-678-9033
Practice Address - Fax:224-678-9493
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.004100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty