Provider Demographics
NPI:1396403606
Name:LUBANS DEHAVEN, TESA LENEE (LM CPM)
Entity Type:Individual
Prefix:
First Name:TESA
Middle Name:LENEE
Last Name:LUBANS DEHAVEN
Suffix:
Gender:F
Credentials:LM CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96024-0585
Mailing Address - Country:US
Mailing Address - Phone:303-845-0630
Mailing Address - Fax:530-503-9803
Practice Address - Street 1:120 TAYLOR STREET
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093
Practice Address - Country:US
Practice Address - Phone:303-845-0630
Practice Address - Fax:530-503-9803
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife