Provider Demographics
NPI:1447988514
Name:KHRAISAT, TASNEEM
Entity type:Individual
Prefix:MRS
First Name:TASNEEM
Middle Name:
Last Name:KHRAISAT
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 1:211 S STATE COLLEGE BLVD # 1111
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-4116
Mailing Address - Country:US
Mailing Address - Phone:714-900-3442
Mailing Address - Fax:
Practice Address - Street 1:12141 BROOKHURST ST STE 101
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2865
Practice Address - Country:US
Practice Address - Phone:714-296-1934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156849106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist