Provider Demographics
NPI:1245967207
Name:MARYAM KHODAEIKALAKI PROFESSIONAL CLINICAL COUNSELOR PC
Entity type:Organization
Organization Name:MARYAM KHODAEIKALAKI PROFESSIONAL CLINICAL COUNSELOR PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODAEIKALAKI
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:310-279-7860
Mailing Address - Street 1:26317 W BRAVO LN
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26317 W BRAVO LN
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-1082
Practice Address - Country:US
Practice Address - Phone:310-279-7860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-01
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty