Provider Demographics
NPI:1184280380
Name:KHANOON, SHAISTA
Entity type:Individual
Prefix:
First Name:SHAISTA
Middle Name:
Last Name:KHANOON
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 1:990 SAINT FRANCIS BLVD APT 1030
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4348
Mailing Address - Country:US
Mailing Address - Phone:510-343-9112
Mailing Address - Fax:
Practice Address - Street 1:990 SAINT FRANCIS BLVD APT 1030
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4348
Practice Address - Country:US
Practice Address - Phone:510-343-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 106S00000X, 390200000X
CA127555172V00000X
CA149787106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program