Provider Demographics
NPI:1306192679
Name:NABULSI, TAREQ (LPT)
Entity Type:Individual
Prefix:
First Name:TAREQ
Middle Name:
Last Name:NABULSI
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2808
Mailing Address - Country:US
Mailing Address - Phone:608-755-7960
Mailing Address - Fax:608-755-7873
Practice Address - Street 1:11741 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3681
Practice Address - Country:US
Practice Address - Phone:562-801-0318
Practice Address - Fax:562-949-3642
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4087390200000X
CAPT40247167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT40247OtherLICENSED PSYCHIATRIC TECHNICIAN