Provider Demographics
NPI:1245858752
Name:MOORE, KHADIJAH
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:MOORE
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 1:1 GALENA CT
Mailing Address - Street 2:
Mailing Address - City:ERIAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-4320
Mailing Address - Country:US
Mailing Address - Phone:973-698-6470
Mailing Address - Fax:
Practice Address - Street 1:1 GALENA CT
Practice Address - Street 2:
Practice Address - City:ERIAL
Practice Address - State:NJ
Practice Address - Zip Code:08081-4320
Practice Address - Country:US
Practice Address - Phone:973-698-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06166800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker