=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235420936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANISHA INEZ SOUTH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2011
-----------------------------------------------------
Last Update Date | 02/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9121 FOLSOM BLVD
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95826-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-743-2661
-----------------------------------------------------
Fax | 916-743-2661
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3239 MIRAMONTE DR
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95833-2624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-473-5766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 102772
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------