Provider Demographics
NPI:1902159122
Name:MODERN PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:MODERN PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PURAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KHALSA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:415-235-9982
Mailing Address - Street 1:6177 GROVEDALE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-2553
Mailing Address - Country:US
Mailing Address - Phone:703-924-2370
Mailing Address - Fax:703-924-2374
Practice Address - Street 1:6177 GROVEDALE CT STE 100
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2553
Practice Address - Country:US
Practice Address - Phone:703-924-2370
Practice Address - Fax:703-924-2374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004653261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health