Provider Demographics
NPI:1033667837
Name:BOAN, TABITHA RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:RENEE
Last Name:BOAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 BUSH LN
Mailing Address - Street 2:
Mailing Address - City:DALZELL
Mailing Address - State:SC
Mailing Address - Zip Code:29040-9724
Mailing Address - Country:US
Mailing Address - Phone:540-589-4248
Mailing Address - Fax:
Practice Address - Street 1:3150 BUSH LN
Practice Address - Street 2:
Practice Address - City:DALZELL
Practice Address - State:SC
Practice Address - Zip Code:29040-9724
Practice Address - Country:US
Practice Address - Phone:540-589-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist