Provider Demographics
NPI:1023560174
Name:JUSTICE, TABATHA LEE
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:LEE
Last Name:JUSTICE
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 1:1023 TEE ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3953
Mailing Address - Country:US
Mailing Address - Phone:815-440-5802
Mailing Address - Fax:
Practice Address - Street 1:2611 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-4151
Practice Address - Country:US
Practice Address - Phone:815-625-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist