Basic Information
| Provider Information | |||||||||
| NPI: | 1518130954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOLODKOV | ||||||||
| FirstName: | TATYANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 995 GATEWAY CENTER WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
| FaxNumber: | 6193982168 | ||||||||
| Practice Location | |||||||||
| Address1: | 995 GATEWAY CENTER WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
| FaxNumber: | 6193982168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.