MEDICARE: MRS. KHADIJA HANKERSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	10802	CT

General Provider Information

NPI Number	:	1487023354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KHADIJA HANKERSON LCSW

Provider Business Mailing Address
First Line	:	401 SHIPPAN AVE STE 204
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-6075
Country	:	US
Telephone Number	:	203-517-3363
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 SHIPPAN AVE STE 204
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-6075
Country	:	US
Telephone Number	:	203-516-3363
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	12/03/2019

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