Provider Demographics
NPI:1376436758
Name:KHAIRUNNISA, HAFSAH LATHIFAH
Entity type:Individual
Prefix:
First Name:HAFSAH
Middle Name:LATHIFAH
Last Name:KHAIRUNNISA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10206 COLESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-2428
Mailing Address - Country:US
Mailing Address - Phone:240-603-8218
Mailing Address - Fax:
Practice Address - Street 1:10206 COLESVILLE RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-2428
Practice Address - Country:US
Practice Address - Phone:240-603-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDBACB1076517106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician