Healthcare Provider Details

I. General information

NPI: 1588265391
Provider Name (Legal Business Name): TATIANA RABANNE MIRANDA CAOAGDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 SUTTERVILLE RD
SACRAMENTO CA
95820-1093
US

IV. Provider business mailing address

9245 LAGUNA SPRINGS DR STE 200
ELK GROVE CA
95758-7991
US

V. Phone/Fax

Practice location:
  • Phone: 916-208-9046
  • Fax:
Mailing address:
  • Phone: 916-208-9046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number22210
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number130145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: