Provider Demographics
NPI:1497540249
Name:KHADEM, SHIRIN
Entity type:Individual
Prefix:MRS
First Name:SHIRIN
Middle Name:
Last Name:KHADEM
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 1:28245 AVENUE CROCKER
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-0940
Mailing Address - Country:US
Mailing Address - Phone:661-287-9730
Mailing Address - Fax:
Practice Address - Street 1:28245 AVENUE CROCKER
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-0940
Practice Address - Country:US
Practice Address - Phone:661-287-9730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician