Provider Demographics
NPI:1104661768
Name:KHAZAK, ELMIRA
Entity type:Individual
Prefix:
First Name:ELMIRA
Middle Name:
Last Name:KHAZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 174TH ST APT 2105
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3256
Mailing Address - Country:US
Mailing Address - Phone:305-458-0697
Mailing Address - Fax:
Practice Address - Street 1:290 174TH ST APT 2105
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-3256
Practice Address - Country:US
Practice Address - Phone:305-458-0697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician