Provider Demographics
NPI:1518308212
Name:TITSWORTH, TABATHA LYNN (MS)
Entity Type:Individual
Prefix:MISS
First Name:TABATHA
Middle Name:LYNN
Last Name:TITSWORTH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15450 NISQUALLI RD
Mailing Address - Street 2:APT. O-204
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8535
Mailing Address - Country:US
Mailing Address - Phone:562-360-5833
Mailing Address - Fax:
Practice Address - Street 1:800 FERRARI
Practice Address - Street 2:SUITE 100
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5030
Practice Address - Country:US
Practice Address - Phone:909-484-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14090103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst