Provider Demographics
NPI:1750855250
Name:HERTZ, TABITHA R
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:R
Last Name:HERTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MARNE RD
Mailing Address - Street 2:
Mailing Address - City:HOPATCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07843-1815
Mailing Address - Country:US
Mailing Address - Phone:973-770-4225
Mailing Address - Fax:
Practice Address - Street 1:130 MARNE RD
Practice Address - Street 2:
Practice Address - City:HOPATCONG
Practice Address - State:NJ
Practice Address - Zip Code:07843-1815
Practice Address - Country:US
Practice Address - Phone:973-770-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NJ1-21-57381103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician