Healthcare Provider Details

I. General information

NPI: 1902159122
Provider Name (Legal Business Name): MODERN PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6177 GROVEDALE CT STE 100
ALEXANDRIA VA
22310-2553
US

IV. Provider business mailing address

6177 GROVEDALE CT STE 100
ALEXANDRIA VA
22310-2553
US

V. Phone/Fax

Practice location:
  • Phone: 703-924-2370
  • Fax: 703-924-2374
Mailing address:
  • Phone: 703-924-2370
  • Fax: 703-924-2374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0810004653
License Number StateVA

VIII. Authorized Official

Name: DR. PURAN S KHALSA
Title or Position: LICENSED PSYCHOLOGIST
Credential: PSYD
Phone: 415-235-9982