Provider Demographics
NPI:1174829964
Name:KHANOM, MOSAMMAT FERDOUSI (MSW)
Entity Type:Individual
Prefix:MS
First Name:MOSAMMAT
Middle Name:FERDOUSI
Last Name:KHANOM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17545 88TH AVE
Mailing Address - Street 2:5B
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-5759
Mailing Address - Country:US
Mailing Address - Phone:347-484-6653
Mailing Address - Fax:
Practice Address - Street 1:17545 88TH AVE
Practice Address - Street 2:5B
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5759
Practice Address - Country:US
Practice Address - Phone:347-484-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2011-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOT YET RECIEVED104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPX35342RMedicaid