Provider Demographics
NPI:1962900381
Name:KHONDKARYAN, ENNA EDWARDOVNA (LCSW)
Entity type:Individual
Prefix:
First Name:ENNA
Middle Name:EDWARDOVNA
Last Name:KHONDKARYAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CROFUT RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-2508
Mailing Address - Country:US
Mailing Address - Phone:203-676-6494
Mailing Address - Fax:203-737-5455
Practice Address - Street 1:40 TEMPLE ST STE 7C
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2715
Practice Address - Country:US
Practice Address - Phone:203-737-5876
Practice Address - Fax:203-737-5455
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0100751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical