Provider Demographics
NPI:1255193512
Name:KHAZZAM, KEREN (MA LMFT)
Entity type:Individual
Prefix:
First Name:KEREN
Middle Name:
Last Name:KHAZZAM
Suffix:
Gender:F
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 KELTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5702
Mailing Address - Country:US
Mailing Address - Phone:310-709-6489
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD STE 1020
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2611
Practice Address - Country:US
Practice Address - Phone:818-668-7513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT112763106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty