Provider Demographics
NPI:1912474461
Name:KHALIQ, NURU
Entity type:Individual
Prefix:
First Name:NURU
Middle Name:
Last Name:KHALIQ
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 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:949-833-2237
Mailing Address - Fax:
Practice Address - Street 1:935B SPRING ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4523
Practice Address - Country:US
Practice Address - Phone:510-337-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2024-09-06
Deactivation Date:2024-08-21
Deactivation Code:
Reactivation Date:2024-09-04
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-74534106S00000X
CAVN744330164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician