Healthcare Provider Details

I. General information

NPI: 1760264956
Provider Name (Legal Business Name): KHADIJAH A FORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652-3607
US

IV. Provider business mailing address

610 VALLEY HEALTH PLZ
PARAMUS NJ
07652-3607
US

V. Phone/Fax

Practice location:
  • Phone: 201-265-8200
  • Fax:
Mailing address:
  • Phone: 201-265-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06646800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: