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NPI Code Detail

MEDICARE: DR. TANISHA FAIRGOOD LMFT

MEDICARE: DR. TANISHA FAIRGOOD LMFT
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
1106H00000XMarriage & Family TherapistIMF69306CA
2106H00000XMarriage & Family Therapist99693CA

General Provider Information

NPI Number : 1275957359
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TANISHA FAIRGOOD LMFT
Provider Business Mailing Address
First Line : 1624 SANTA CLARA DR.
Second Line : SUITE 145
City : ROSEVILLE
State : CA
Zip : 95661
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1624 SANTA CLARA DR STE 145
Second Line :
City : ROSEVILLE
State : CA
Zip : 95661-3500
Country : US
Telephone Number : 916-206-8548
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/10/2014
Last Update Date : 02/11/2022

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