Provider Demographics
NPI:1679987887
Name:KETABCHI, MAHMOOD (LMFT)
Entity type:Individual
Prefix:MR
First Name:MAHMOOD
Middle Name:
Last Name:KETABCHI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6447
Mailing Address - Country:US
Mailing Address - Phone:510-697-8290
Mailing Address - Fax:925-848-0331
Practice Address - Street 1:3700 DELTA FAIR BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4074
Practice Address - Country:US
Practice Address - Phone:510-697-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106345106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist