Provider Demographics
NPI:1376081935
Name:TABBERT, JANELL
Entity Type:Individual
Prefix:
First Name:JANELL
Middle Name:
Last Name:TABBERT
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 1:1801 S 4J RD
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5201
Mailing Address - Country:US
Mailing Address - Phone:307-682-2392
Mailing Address - Fax:
Practice Address - Street 1:1801 S 4J RD
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5201
Practice Address - Country:US
Practice Address - Phone:307-682-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-815235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYSP-815OtherSTATE OF WYOMING