Provider Demographics
NPI:1790244127
Name:HAGANS, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:HAGANS
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 1:200 N YALE ST APT 219
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-4719
Mailing Address - Country:US
Mailing Address - Phone:951-581-7751
Mailing Address - Fax:
Practice Address - Street 1:790 S STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4924
Practice Address - Country:US
Practice Address - Phone:951-654-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC5770101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional