Provider Demographics
NPI:1669916110
Name:AZZAM, CZARINA VICTORIA (LPC, PHD)
Entity type:Individual
Prefix:
First Name:CZARINA
Middle Name:VICTORIA
Last Name:AZZAM
Suffix:
Gender:F
Credentials:LPC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 SUNWEST LN SAN BERNARDINO CA 92415
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0001
Mailing Address - Country:US
Mailing Address - Phone:832-881-8990
Mailing Address - Fax:
Practice Address - Street 1:9401 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1407
Practice Address - Country:US
Practice Address - Phone:713-970-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
76606103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor