Provider Demographics
NPI:1841618402
Name:BURKHART-WILSON, TABITHA (LPP)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:BURKHART-WILSON
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 TIMBERNECK CV
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8539
Mailing Address - Country:US
Mailing Address - Phone:859-200-1650
Mailing Address - Fax:
Practice Address - Street 1:3125 TIMBERNECK CV
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-8539
Practice Address - Country:US
Practice Address - Phone:859-200-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0105103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist