Provider Demographics
NPI:1144320409
Name:DOCTOR, TASNEEM (EDD)
Entity type:Individual
Prefix:DR
First Name:TASNEEM
Middle Name:
Last Name:DOCTOR
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:DR
Other - First Name:TASNEEM
Other - Middle Name:
Other - Last Name:DOCTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5850 ROCKY SHORE DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-7993
Mailing Address - Country:US
Mailing Address - Phone:614-746-9159
Mailing Address - Fax:614-457-0026
Practice Address - Street 1:3305 N 25TH PL
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7427
Practice Address - Country:US
Practice Address - Phone:602-525-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3924103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004692Medicaid
AZ191019Medicaid