Provider Demographics
NPI:1508580945
Name:KEITA, TABETHA TAPIWA-ROSE
Entity Type:Individual
Prefix:
First Name:TABETHA
Middle Name:TAPIWA-ROSE
Last Name:KEITA
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:PO BOX 2036
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-8036
Mailing Address - Country:US
Mailing Address - Phone:732-270-4823
Mailing Address - Fax:732-270-4951
Practice Address - Street 1:414 MARC DR
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-4228
Practice Address - Country:US
Practice Address - Phone:732-270-4823
Practice Address - Fax:732-270-4951
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid