Provider Demographics
NPI:1558028043
Name:TABARES, SERGIO JR
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:TABARES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 S DOBSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-6412
Mailing Address - Country:US
Mailing Address - Phone:480-757-8090
Mailing Address - Fax:
Practice Address - Street 1:2266 S DOBSON RD STE 200
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-6412
Practice Address - Country:US
Practice Address - Phone:480-757-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-188070106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician