Provider Demographics
NPI:1609544782
Name:MANZOOR, KHADIJA
Entity Type:Individual
Prefix:
First Name:KHADIJA
Middle Name:
Last Name:MANZOOR
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 1:5816 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3344
Mailing Address - Country:US
Mailing Address - Phone:312-813-8842
Mailing Address - Fax:
Practice Address - Street 1:501 DAVIS ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4619
Practice Address - Country:US
Practice Address - Phone:312-815-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL500642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health