Provider Demographics
NPI:1114200136
Name:TAXDAHL, CLINTON
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:
Last Name:TAXDAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 FAIR OAKS BLVD
Mailing Address - Street 2:STE. 440
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-5533
Mailing Address - Country:US
Mailing Address - Phone:916-441-0123
Mailing Address - Fax:
Practice Address - Street 1:719 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-2501
Practice Address - Country:US
Practice Address - Phone:916-444-3118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker