Provider Demographics
NPI:1114419678
Name:SIDRAH KHAN PSYCHOTHERAPY PC
Entity Type:Organization
Organization Name:SIDRAH KHAN PSYCHOTHERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIDRAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-447-9526
Mailing Address - Street 1:4714 N NYSTROM PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242 N 8TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-447-9526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty