Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | 024036 | CT |
NPI | 1104870252 |
---|---|
Provider Name | Mrs. Mujeeb Khalique |
First Address | West Hartford, CT 06107-2402 |
Second Address | West Hartford, CT 06107-2441 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C59663 | (02) | CT |