Healthcare Provider Details

I. General information

NPI: 1003781485
Provider Name (Legal Business Name): TANESHA NIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 GRANT ST
VALLEJO CA
94590-7228
US

IV. Provider business mailing address

13 VILLA CT
FAIRFIELD CA
94533-2526
US

V. Phone/Fax

Practice location:
  • Phone: 707-553-1042
  • Fax:
Mailing address:
  • Phone: 707-342-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: