Basic Information
| Provider Information | |||||||||
| NPI: | 1538794656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | HUSSAIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 BEECH ST | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010403968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135401100 | ||||||||
| FaxNumber: | 4135331016 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 BEECH ST | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010403968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135401100 | ||||||||
| FaxNumber: | 4135432601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2020 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4722 | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1309102 | 05 | MA | MEDICAID | 1309129 | 05 | MA | MEDICAID | 1308602 | 05 | MA | MEDICAID | 1301217 | 05 | MA | MEDICAID |