Provider Demographics
NPI:1770200396
Name:OLDJOHN, KHALIPA K (BCBA)
Entity type:Individual
Prefix:MR
First Name:KHALIPA
Middle Name:K
Last Name:OLDJOHN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 BOLTON RD
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-5507
Mailing Address - Country:US
Mailing Address - Phone:609-216-8468
Mailing Address - Fax:
Practice Address - Street 1:365 BOLTON RD
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:NJ
Practice Address - Zip Code:08520-5507
Practice Address - Country:US
Practice Address - Phone:609-216-8468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-22-62059103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst