Provider Demographics
NPI:1669941209
Name:KHALSA, MUKTA KAUR (PMHC, LADAC)
Entity type:Individual
Prefix:
First Name:MUKTA
Middle Name:KAUR
Last Name:KHALSA
Suffix:
Gender:F
Credentials:PMHC, LADAC
Other - Prefix:
Other - First Name:MUKTA
Other - Middle Name:KAUR
Other - Last Name:KHALSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHC, LADAC
Mailing Address - Street 1:PO BOX 94508
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-4508
Mailing Address - Country:US
Mailing Address - Phone:505-384-7352
Mailing Address - Fax:505-274-7338
Practice Address - Street 1:1 RAM DAS GURU PL
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-8213
Practice Address - Country:US
Practice Address - Phone:505-699-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0397101YM0800X
NMCAD3416101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)