Provider Demographics
NPI:1932649290
Name:MCCLOUD, KHADIJAH ANN- MONIQUE
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:ANN- MONIQUE
Last Name:MCCLOUD
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 1:53869 CONNOR DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48051-3930
Mailing Address - Country:US
Mailing Address - Phone:773-241-4009
Mailing Address - Fax:
Practice Address - Street 1:53869 CONNOR DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3930
Practice Address - Country:US
Practice Address - Phone:773-241-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician