Provider Demographics
NPI:1912041484
Name:KEZEL, FARIBA (PHD)
Entity Type:Individual
Prefix:DR
First Name:FARIBA
Middle Name:
Last Name:KEZEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:FARIBA
Other - Middle Name:
Other - Last Name:EBRAHIM KHAN KHEZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4199 CAMPUS DR
Mailing Address - Street 2:SUITE 550
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-4696
Mailing Address - Country:US
Mailing Address - Phone:714-490-4965
Mailing Address - Fax:949-509-6599
Practice Address - Street 1:4199 CAMPUS DR
Practice Address - Street 2:SUITE 550
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-4696
Practice Address - Country:US
Practice Address - Phone:714-490-4965
Practice Address - Fax:949-509-6599
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20295103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical