Provider Demographics
NPI:1063535011
Name:KHAVAR, VIDA (MA, MFT)
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:
Last Name:KHAVAR
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 N GRAND AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-3520
Mailing Address - Country:US
Mailing Address - Phone:818-458-4050
Mailing Address - Fax:
Practice Address - Street 1:760 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4925
Practice Address - Country:US
Practice Address - Phone:626-246-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40809106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist