Provider Demographics
NPI:1235420936
Name:SOUTH, TANISHA INEZ
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:INEZ
Last Name:SOUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3239 MIRAMONTE DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2624
Mailing Address - Country:US
Mailing Address - Phone:916-473-5766
Mailing Address - Fax:
Practice Address - Street 1:9121 FOLSOM BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2473
Practice Address - Country:US
Practice Address - Phone:916-743-2661
Practice Address - Fax:916-743-2661
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102772106H00000X, 106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist