Provider Demographics
NPI:1689331464
Name:TRAN, MIMI KATIE
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:KATIE
Last Name:TRAN
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 1:2924 WEALD WAY APT 1224
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8801 FOLSOM BLVD
Practice Address - Street 2:SUITE #265
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician