Provider Demographics
NPI:1861128811
Name:KHAN, SHALESTA
Entity type:Individual
Prefix:
First Name:SHALESTA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAESTA
Other - Middle Name:
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:400 ESTUDILLO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4999
Mailing Address - Country:US
Mailing Address - Phone:510-924-0548
Mailing Address - Fax:
Practice Address - Street 1:400 ESTUDILLO AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4999
Practice Address - Country:US
Practice Address - Phone:510-924-0548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-30
Last Update Date:2023-03-27
Deactivation Date:2023-02-10
Deactivation Code:
Reactivation Date:2023-03-27
Provider Licenses
StateLicense IDTaxonomies
CA94027219103TC0700X, 390200000X, 103T00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health