Provider Demographics
NPI:1770374324
Name:FARRUKHZODA, NOZANIN
Entity type:Individual
Prefix:
First Name:NOZANIN
Middle Name:
Last Name:FARRUKHZODA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 FEDERAL HILL RD # 204
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-2046
Mailing Address - Country:US
Mailing Address - Phone:224-531-7361
Mailing Address - Fax:
Practice Address - Street 1:73 ELM ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-2813
Practice Address - Country:US
Practice Address - Phone:224-531-7361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-386193106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician