Provider Demographics
NPI:1396226734
Name:KING, KHADIJAH
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 CALDERONE CT
Mailing Address - Street 2:
Mailing Address - City:S PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-3983
Mailing Address - Country:US
Mailing Address - Phone:973-865-2072
Mailing Address - Fax:
Practice Address - Street 1:10 PARSONAGE RD STE 318
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2429
Practice Address - Country:US
Practice Address - Phone:732-204-1635
Practice Address - Fax:732-204-1636
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-17-40273106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician