Provider Demographics
NPI:1609028026
Name:KHADEMI KALANTARI, PRISCILLA MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:MARIE
Last Name:KHADEMI KALANTARI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:MARIE
Other - Last Name:PALACIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMFT
Mailing Address - Street 1:3246 ARUNDALA WAY
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77808-1490
Mailing Address - Country:US
Mailing Address - Phone:979-307-0479
Mailing Address - Fax:979-205-5312
Practice Address - Street 1:3246 ARUNDALA WAY
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77808-1490
Practice Address - Country:US
Practice Address - Phone:979-307-0479
Practice Address - Fax:979-205-5312
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT126805106H00000X
TX204185106H00000X
CAIMF 60189101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health