Provider Demographics
NPI:1629501143
Name:TABBARA, MAHA (TLLP)
Entity Type:Individual
Prefix:
First Name:MAHA
Middle Name:
Last Name:TABBARA
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5532 CYPRESS BAY DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-7755
Mailing Address - Country:US
Mailing Address - Phone:269-870-6522
Mailing Address - Fax:
Practice Address - Street 1:1050 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5580
Practice Address - Country:US
Practice Address - Phone:269-965-8078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM188076103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist