Provider Demographics
NPI:1770271876
Name:KHAWAJA, TATIANA JACQUELINE
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:JACQUELINE
Last Name:KHAWAJA
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 1:405 N INDIAN HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4614
Mailing Address - Country:US
Mailing Address - Phone:323-207-0076
Mailing Address - Fax:
Practice Address - Street 1:405 N INDIAN HILL BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4614
Practice Address - Country:US
Practice Address - Phone:626-675-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-26
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA144105106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program