Provider Demographics
NPI:1346777034
Name:FADIKA, TIGIDANKAY KASANTI
Entity Type:Individual
Prefix:
First Name:TIGIDANKAY
Middle Name:KASANTI
Last Name:FADIKA
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 1:4088 ICE HOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-8919
Mailing Address - Country:US
Mailing Address - Phone:916-813-0066
Mailing Address - Fax:
Practice Address - Street 1:4088 ICE HOUSE WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-8919
Practice Address - Country:US
Practice Address - Phone:916-813-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician