Provider Demographics
NPI:1063001030
Name:ALICOCK, TALIAH HALEEMA (MED)
Entity Type:Individual
Prefix:
First Name:TALIAH
Middle Name:HALEEMA
Last Name:ALICOCK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-1460
Mailing Address - Country:US
Mailing Address - Phone:908-943-1787
Mailing Address - Fax:
Practice Address - Street 1:651 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-1460
Practice Address - Country:US
Practice Address - Phone:908-943-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
NJ106S00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No252Y00000XAgenciesEarly Intervention Provider Agency
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ02041984Medicaid