Healthcare Provider Details

I. General information

NPI: 1366353716
Provider Name (Legal Business Name): KENOUZ KHALIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WALNUT AVE STE 210
CLARK NJ
07066-1269
US

IV. Provider business mailing address

100 WALNUT AVE STE 210
CLARK NJ
07066-1269
US

V. Phone/Fax

Practice location:
  • Phone: 732-454-7810
  • Fax: 732-454-7811
Mailing address:
  • Phone: 732-454-7810
  • Fax: 732-454-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC01000900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: