Provider Demographics
NPI:1417208828
Name:KAHN, MIMI (MSW,LCSW)
Entity type:Individual
Prefix:MRS
First Name:MIMI
Middle Name:
Last Name:KAHN
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7719
Mailing Address - Country:US
Mailing Address - Phone:714-576-6464
Mailing Address - Fax:
Practice Address - Street 1:218 W MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7719
Practice Address - Country:US
Practice Address - Phone:714-576-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical