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General NPI Number Information
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NPI Number | 1902159122
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Entity Type | Organization
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Legal Business Name | MODERN PSYCHOLOGICAL SERVICES LLC
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Dates
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Enumeration Date | 10/25/2012
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Last Update Date | 10/25/2012
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Provider Practice Location Address
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Address Line | 6177 GROVEDALE CT STE 100
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City | ALEXANDRIA
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State | VA
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Zip | 22310-2553
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Country | US
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Telephone | 703-924-2370
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Fax | 703-924-2374
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Provider Business Mailing Address
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Address Line | 6177 GROVEDALE CT STE 100
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City | ALEXANDRIA
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State | VA
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Zip | 22310-2553
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Country | US
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Telephone | 703-924-2370
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Fax | 703-924-2374
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. PURAN S KHALSA
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Credential | PSYD
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Telephone | 415-235-9982
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 0810004653
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License Number State | VA
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