Provider Demographics
NPI:1083500276
Name:KHAN, MOLLY ROSE (LEP)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:ROSE
Last Name:KHAN
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 MARTIN CIR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3375
Mailing Address - Country:US
Mailing Address - Phone:559-999-6069
Mailing Address - Fax:
Practice Address - Street 1:957 MARTIN CIR
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3375
Practice Address - Country:US
Practice Address - Phone:559-999-6069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4320103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist