Provider Demographics
NPI:1679910475
Name:WEST, TABITHA J (DT)
Entity Type:Individual
Prefix:MS
First Name:TABITHA
Middle Name:J
Last Name:WEST
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11385 EDGEMERE TER
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8200
Mailing Address - Country:US
Mailing Address - Phone:815-319-2933
Mailing Address - Fax:
Practice Address - Street 1:11385 EDGEMERE TER
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-8200
Practice Address - Country:US
Practice Address - Phone:815-319-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst