Provider Demographics
NPI:1710212196
Name:BALL, TABITHA DELAINA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TABITHA
Middle Name:DELAINA
Last Name:BALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 MARKETPLACE BLVD STE 130-669
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5747
Mailing Address - Country:US
Mailing Address - Phone:404-217-8657
Mailing Address - Fax:
Practice Address - Street 1:1001 VIRGINIA AVE STE 210
Practice Address - Street 2:
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354-1367
Practice Address - Country:US
Practice Address - Phone:404-218-8657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004529103T00000X
GAPSY003839103T00000X, 103TB0200X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003183738CMedicaid