Provider Demographics
NPI:1568661700
Name:KHANUJA, LYNN T (MA, LPC, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:T
Last Name:KHANUJA
Suffix:
Gender:F
Credentials:MA, LPC, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0280
Mailing Address - Country:US
Mailing Address - Phone:573-686-1200
Mailing Address - Fax:573-686-1029
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:573-686-1029
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003032241101YP2500X
MO20030322241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
431116734OtherEAP INTERFACE
11514082OtherCAQH
2258OtherEAP IMPACT
431116734OtherEAP DEER OAKS
000000450401OtherBLUE CROSS BLUE SHIELD
MO475106027Medicaid
MO495106007Medicaid