Provider Demographics
NPI:1346928710
Name:LEQUE, TABITHA MARIE (APSW)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:MARIE
Last Name:LEQUE
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-5309
Mailing Address - Country:US
Mailing Address - Phone:920-904-6762
Mailing Address - Fax:
Practice Address - Street 1:N5682 COUNTY ROAD K
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-7908
Practice Address - Country:US
Practice Address - Phone:877-300-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134414-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical