=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316804750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KHAN INTERSTELLAR PSYCHOLOGY AND CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2026
-----------------------------------------------------
Last Update Date | 01/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 N BERKELEY LAKE RD NW FL 1
-----------------------------------------------------
City | BERKELEY LAKE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-3187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-331-4882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 MISTY GROVE DR
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-9054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-566-5841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. HUMAMA KHAN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 843-566-5841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------