Provider Demographics
NPI:1518670041
Name:TABBERT, KEYARA J (MFT)
Entity Type:Individual
Prefix:
First Name:KEYARA
Middle Name:J
Last Name:TABBERT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W10174 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMP DOUGLAS
Mailing Address - State:WI
Mailing Address - Zip Code:54618-9709
Mailing Address - Country:US
Mailing Address - Phone:608-344-0053
Mailing Address - Fax:
Practice Address - Street 1:1216 MARK AVE STE 6
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1199
Practice Address - Country:US
Practice Address - Phone:608-344-0053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist