Provider Demographics
NPI:1528574514
Name:KHALSA, ADI K (RBT)
Entity Type:Individual
Prefix:
First Name:ADI
Middle Name:K
Last Name:KHALSA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 LEGION WAY SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1843
Mailing Address - Country:US
Mailing Address - Phone:360-561-8162
Mailing Address - Fax:
Practice Address - Street 1:3443 LILLY RD NE STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-3091
Practice Address - Country:US
Practice Address - Phone:360-456-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00000000000106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0000000000OtherRBT