Provider Demographics
NPI:1659132652
Name:TABOR, ANTHONY JACOB (MED CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JACOB
Last Name:TABOR
Suffix:
Gender:M
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 12TH ST NE UNIT 1001
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-4071
Mailing Address - Country:US
Mailing Address - Phone:501-626-6974
Mailing Address - Fax:
Practice Address - Street 1:222 12TH ST NE UNIT 1001
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-4071
Practice Address - Country:US
Practice Address - Phone:501-626-6974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007460235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty