Provider Demographics
NPI:1336520550
Name:KHOUKAZ, KATHLYN A (PSYD)
Entity type:Individual
Prefix:
First Name:KATHLYN
Middle Name:A
Last Name:KHOUKAZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 CENTER DR # 105-7047
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-3500
Mailing Address - Country:US
Mailing Address - Phone:760-462-5663
Mailing Address - Fax:
Practice Address - Street 1:711 CENTER DR # 105-7047
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-3500
Practice Address - Country:US
Practice Address - Phone:760-402-9103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-12
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3264103TC0700X
390200000X
CA33541103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program