Provider Demographics
NPI:1649705344
Name:MIRZA, KHADEEJA S
Entity type:Individual
Prefix:
First Name:KHADEEJA
Middle Name:S
Last Name:MIRZA
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:PO BOX 1753
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-0059
Mailing Address - Country:US
Mailing Address - Phone:310-706-8897
Mailing Address - Fax:
Practice Address - Street 1:2702 CLAYTON RD
Practice Address - Street 2:207
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94519-2789
Practice Address - Country:US
Practice Address - Phone:925-771-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA735851041C0700X
CA1010271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker