Provider Demographics
NPI:1114510609
Name:KHAWAJA, RUNA
Entity type:Individual
Prefix:
First Name:RUNA
Middle Name:
Last Name:KHAWAJA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RUNA
Other - Middle Name:
Other - Last Name:KHANOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2705
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:
Practice Address - Street 1:85 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-1803
Practice Address - Country:US
Practice Address - Phone:860-224-3642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00310700101YA0400X
NJ37PC00681200101YP2500X
CT4598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)