Provider Demographics
NPI:1972071942
Name:SUPER, TABETHA (DC)
Entity Type:Individual
Prefix:DR
First Name:TABETHA
Middle Name:
Last Name:SUPER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19604-1840
Mailing Address - Country:US
Mailing Address - Phone:563-514-5444
Mailing Address - Fax:
Practice Address - Street 1:1440 BIRCH ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19604-1840
Practice Address - Country:US
Practice Address - Phone:563-514-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor