Provider Demographics
NPI:1326546714
Name:NOLDA, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:NOLDA
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 1:412 S LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-2617
Mailing Address - Country:US
Mailing Address - Phone:618-593-0811
Mailing Address - Fax:
Practice Address - Street 1:100 S 4TH ST STE 550
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63102-1897
Practice Address - Country:US
Practice Address - Phone:314-797-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017044726101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1326546714Medicaid