Provider Demographics
NPI:1669823829
Name:KHORASANI, TALITHA
Entity Type:Individual
Prefix:
First Name:TALITHA
Middle Name:
Last Name:KHORASANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TALITHA
Other - Middle Name:MARIE
Other - Last Name:JESSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16333 RIDGEHAVEN DR UNIT 1002
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1481
Mailing Address - Country:US
Mailing Address - Phone:925-719-0019
Mailing Address - Fax:
Practice Address - Street 1:3705 BEACON AVE STE 101
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1467
Practice Address - Country:US
Practice Address - Phone:925-719-0019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
AZ390200000X
CA108674122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program