Healthcare Provider Details

I. General information

NPI: 1598967242
Provider Name (Legal Business Name): TALEB S KHAIRALLAH MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 S PROVIDENCE RD BLDG E
COLUMBIA MO
65203-3624
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2511
  • Fax: 573-884-5936
Mailing address:
  • Phone: 573-882-2259
  • Fax: 573-884-8526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2006020295
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number335130-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: