Basic Information
| Provider Information | |||||||||
| NPI: | 1396104865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETABCHI | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11835 W OLYMPIC BLVD STE 1265E | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900645814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102734843 | ||||||||
| FaxNumber: | 3102735056 | ||||||||
| Practice Location | |||||||||
| Address1: | 11835 W OLYMPIC BLVD STE 1265E | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900645814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102734843 | ||||||||
| FaxNumber: | 3102735056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2016 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY27919 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 835383 | 05 | CA | MEDICAID |