MEDICARE: KALEIDO PSYCHOLOGICAL SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1962179978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALEIDO PSYCHOLOGICAL SERVICES, INC

Provider Business Mailing Address
First Line	:	2010 EL CAMINO REAL # 2096
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95050-4051
Country	:	US
Telephone Number	:	408-883-9696
Fax Number	:

Provider Business Practice Location Address
First Line	:	3575 LEHIGH DR APT 13
Second Line	:
City	:	SANTA CLARA
State	:	CA
Zip	:	95051-6073
Country	:	US
Telephone Number	:	408-883-9696
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER/CLINICAL PSYCHOLOGIST
Name	:	DR. LAURA KHOURY
Credential	:	PHD
Telephone Number	:	408-883-9696

Provider Enumeration Date	:	08/26/2021
Last Update Date	:	08/26/2021

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