Provider Demographics
NPI:1275022055
Name:SHAIK, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:SHAIK
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 1:2973 HARBOR BLVD # 136
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10532 ACACIA ST STE B11
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5444
Practice Address - Country:US
Practice Address - Phone:818-844-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician