=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306625876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHALSA PSYCHOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2023
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 N HUMPHREYS
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-985-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 S WOODLANDS VILLAGE BLVD STE 300 PMB 295
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 192-898-5855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. KARAMBIR KHALSA
-----------------------------------------------------
Credential | LP
-----------------------------------------------------
Telephone | 928-985-8550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------