Basic Information
| Provider Information | |||||||||
| NPI: | 1104157726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHALSA | ||||||||
| FirstName: | GURUDARSHAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MFT-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 CAMINO PALMERO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900462902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238760550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1701 CAMINO PALMERO ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900462902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238760550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2010 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 74833 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.