Provider Demographics
NPI:1821356098
Name:KHANG, MAINHIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAINHIA
Middle Name:
Last Name:KHANG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 DUNLAP ST N STE 105
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4211
Mailing Address - Country:US
Mailing Address - Phone:651-212-4877
Mailing Address - Fax:651-212-4872
Practice Address - Street 1:393 DUNLAP ST N STE 105
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4211
Practice Address - Country:US
Practice Address - Phone:651-212-4877
Practice Address - Fax:651-212-4872
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2730106H00000X
MNLP6273103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1821356098Medicaid