Provider Demographics
NPI:1437933728
Name:KEITH, TABITHA J
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:J
Last Name:KEITH
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 1:710 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67871-1412
Mailing Address - Country:US
Mailing Address - Phone:785-743-8491
Mailing Address - Fax:
Practice Address - Street 1:710 W 12TH ST
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:KS
Practice Address - Zip Code:67871-1412
Practice Address - Country:US
Practice Address - Phone:785-743-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW128221041C0700X
KS12822104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker