Healthcare Provider Details

I. General information

NPI: 1699930958
Provider Name (Legal Business Name): VINITA KHANNA MED, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 BERRYWOOD DR STE 101
COLUMBIA MO
65201-6515
US

IV. Provider business mailing address

1300 E BRADFORD PKWY
SPRINGFIELD MO
65804-4264
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-8455
  • Fax:
Mailing address:
  • Phone: 417-761-5000
  • Fax: 417-761-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2008019003
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: