Healthcare Provider Details

I. General information

NPI: 1548682792
Provider Name (Legal Business Name): KHADIJA C. PROWELL BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1178 BROADWAY 3RD FLOOR #4400
NEW YORK NY
10001-5404
US

IV. Provider business mailing address

1178 BROADWAY 3RD FLOOR #4400
NEW YORK NY
10001
US

V. Phone/Fax

Practice location:
  • Phone: 347-244-9763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number002595
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: