Basic Information
| Provider Information | |||||||||
| NPI: | 1245390566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHANJIAN | ||||||||
| FirstName: | ELIZA | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 W ROUTE 66 STE 202 | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
| FaxNumber: | 6269639543 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 N PACIFIC AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912024316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183965343 | ||||||||
| FaxNumber: | 8185613997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | PSY19586 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TC1900X | PSY19586 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 00CP195860 | 05 | CA | MEDICAID |