Basic Information
| Provider Information | |||||||||
| NPI: | 1669941209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHALSA | ||||||||
| FirstName: | MUKTA | ||||||||
| MiddleName: | KAUR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMHC, LADAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KHALSA | ||||||||
| OtherFirstName: | MUKTA | ||||||||
| OtherMiddleName: | KAUR | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMHC, LADAC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 94508 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871994508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 RAM DAS GURU PL | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875328213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056996505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2018 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0397 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | CAD3416 | NM | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.