Provider Demographics
NPI:1235735663
Name:SULTANI, KHALED A
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:A
Last Name:SULTANI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608
Mailing Address - Country:US
Mailing Address - Phone:508-841-3764
Mailing Address - Fax:
Practice Address - Street 1:27 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-841-3764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1225091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical