Provider Demographics
NPI:1285075440
Name:AL-FARAJ, KHADIJAH (BCBA)
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:AL-FARAJ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 BROOKSIDE RD STE 140
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2359
Mailing Address - Country:US
Mailing Address - Phone:209-521-4791
Mailing Address - Fax:209-521-4794
Practice Address - Street 1:3244 BROOKSIDE RD STE 140
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2359
Practice Address - Country:US
Practice Address - Phone:209-521-4791
Practice Address - Fax:209-521-4794
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-13495103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst