Provider Demographics
NPI:1912303660
Name:KHAN, MAVISH (LCSW)
Entity Type:Individual
Prefix:
First Name:MAVISH
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MAVISH
Other - Middle Name:
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1700 NORTHSIDE DR
Mailing Address - Street 2:SUITE A7, UNIT #6083
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:1700 NORTHSIDE DR
Practice Address - Street 2:SUITE A7, UNIT #6083
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318
Practice Address - Country:US
Practice Address - Phone:404-504-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW005286101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA069956712OtherDRIVER'S LICENSE