Provider Demographics
NPI:1265941017
Name:MKHITARIAN, LILY AMANDA (MA)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:AMANDA
Last Name:MKHITARIAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W CARSON ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2023-09-14
Deactivation Date:2019-07-28
Deactivation Code:
Reactivation Date:2023-09-12
Provider Licenses
StateLicense IDTaxonomies
IA115437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical