Healthcare Provider Details

I. General information

NPI: 1225494248
Provider Name (Legal Business Name): SADHU KHALSA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

IV. Provider business mailing address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-8978
  • Fax: 505-383-1191
Mailing address:
  • Phone: 505-841-8978
  • Fax: 505-383-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC2886
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: