Provider Demographics
NPI:1679204291
Name:CROSS, TANISHA DENEE MARIE (RADT)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:DENEE MARIE
Last Name:CROSS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SPAANS DR STE C
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8609
Mailing Address - Country:US
Mailing Address - Phone:209-744-9909
Mailing Address - Fax:209-744-9910
Practice Address - Street 1:750 SPAANS DR STE C
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-8609
Practice Address - Country:US
Practice Address - Phone:209-744-9909
Practice Address - Fax:209-744-9910
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAR1472650622101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)