Healthcare Provider Details

I. General information

NPI: 1710899570
Provider Name (Legal Business Name): TAMARA BAGANZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 LIVING OAK CT
SANTA ROSA CA
95401-5727
US

IV. Provider business mailing address

521 LIVING OAK CT
SANTA ROSA CA
95401-5727
US

V. Phone/Fax

Practice location:
  • Phone: 626-233-0834
  • Fax:
Mailing address:
  • Phone: 626-233-0834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP12031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: