Provider Demographics
NPI:1275076267
Name:BASHKIHARATEE, KISHA (PHD)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:BASHKIHARATEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24691 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24691 STEWART ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2744
Practice Address - Country:US
Practice Address - Phone:985-628-0682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
CA1762101YP2500X
CA10181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1762OtherBOARD OF BEHAVIORAL SCIENCES
CA10181OtherBOARD OF BEHAVIORAL SCIENCES