Provider Demographics
NPI:1780775742
Name:KHATCHIKIAN, AUDREY (PHD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:KHATCHIKIAN
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 1:100 N BRAND BLVD
Mailing Address - Street 2:#606
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2614
Mailing Address - Country:US
Mailing Address - Phone:818-476-0066
Mailing Address - Fax:818-246-5532
Practice Address - Street 1:100 N BRAND BLVD
Practice Address - Street 2:#507
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2614
Practice Address - Country:US
Practice Address - Phone:818-476-0066
Practice Address - Fax:818-246-5532
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18823103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP18823AMedicare ID - Type Unspecified