Provider Demographics
NPI:1679724132
Name:KHALIQUE, MARIAM (LCSW)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:KHALIQUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 W 23RD ST
Mailing Address - Street 2:BRIGHTPOINT HEALTH- HEADQUARTERS
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 W 23RD ST
Practice Address - Street 2:BRIGHTPOINT HEALTH- HEADQUARTERS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4102
Practice Address - Country:US
Practice Address - Phone:718-681-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
LCSW-R1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical