Provider Demographics
NPI:1790719755
Name:KHAZANOV, NATASHA SHOLOM (PHD)
Entity Type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:SHOLOM
Last Name:KHAZANOV
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 MIRALOMA DR
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1643
Mailing Address - Country:US
Mailing Address - Phone:415-665-4490
Mailing Address - Fax:415-665-4490
Practice Address - Street 1:529 IRVING ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2599
Practice Address - Country:US
Practice Address - Phone:415-665-4490
Practice Address - Fax:415-665-4490
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL149170Medicare ID - Type Unspecified
CAS36778Medicare UPIN