Healthcare Provider Details

I. General information

NPI: 1821356098
Provider Name (Legal Business Name): MAINHIA KHANG PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 ENERGY LN STE 215
SAINT PAUL MN
55108-5501
US

IV. Provider business mailing address

1350 ENERGY LN STE 215
SAINT PAUL MN
55108-5501
US

V. Phone/Fax

Practice location:
  • Phone: 651-212-4877
  • Fax: 651-212-4872
Mailing address:
  • Phone: 651-212-5088
  • Fax: 651-212-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6273
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: