Provider Demographics
NPI:1265129019
Name:WATLEY, KHADIJAH
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:WATLEY
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 1:13231 ALCOTT FOREST LN
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-0350
Mailing Address - Country:US
Mailing Address - Phone:337-304-5025
Mailing Address - Fax:
Practice Address - Street 1:8354 E NORTHFIELD BLVD UNIT 3700
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-3135
Practice Address - Country:US
Practice Address - Phone:337-304-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TXRBT-23-272875106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician