Provider Demographics
NPI:1871635011
Name:BRANDT-TIVEN, TABITHA ELLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TABITHA
Middle Name:ELLEN
Last Name:BRANDT-TIVEN
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 1:17-23 UTOPIA PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357
Mailing Address - Country:US
Mailing Address - Phone:516-713-3408
Mailing Address - Fax:516-221-4709
Practice Address - Street 1:2415 JERUSALEM AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710
Practice Address - Country:US
Practice Address - Phone:516-713-3408
Practice Address - Fax:516-221-4709
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical