Provider Demographics
NPI:1619599701
Name:TABB, VICTORIA MARIE (HPT, HHP)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MARIE
Last Name:TABB
Suffix:
Gender:F
Credentials:HPT, HHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 CAMINO DE LOS MARES STE 218
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2807
Mailing Address - Country:US
Mailing Address - Phone:570-573-8993
Mailing Address - Fax:
Practice Address - Street 1:647 CAMINO DE LOS MARES STE 218
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2807
Practice Address - Country:US
Practice Address - Phone:949-899-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79200225700000X
CAH34933101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty