MEDICARE: TANYIA KHADEM MA. CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP-15029	CA

General Provider Information

NPI Number	:	1801744313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANYIA KHADEM MA. CCC-SLP

Provider Business Mailing Address
First Line	:	1282 BRADFORD CT
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91786-3419
Country	:	US
Telephone Number	:	909-772-8909
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 E FOOTHILL BLVD
Second Line	:
City	:	GLENDORA
State	:	CA
Zip	:	91741-3024
Country	:	US
Telephone Number	:	626-963-5731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2026
Last Update Date	:	03/19/2026

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