Provider Demographics
NPI:1972138444
Name:LARRIMORE, TABITHA NICOLE (BA, SC, TC, BSP)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:NICOLE
Last Name:LARRIMORE
Suffix:
Gender:F
Credentials:BA, SC, TC, BSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2468 ROCK CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-5062
Mailing Address - Country:US
Mailing Address - Phone:304-350-1109
Mailing Address - Fax:304-350-8741
Practice Address - Street 1:2468 ROCK CLIFF DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25403-5062
Practice Address - Country:US
Practice Address - Phone:304-350-1109
Practice Address - Fax:304-350-8741
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV171M00000XMedicaid