Provider Demographics
NPI:1982188140
Name:BERNAL, TABITHA (LMFT, NCC)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:BERNAL
Suffix:
Gender:F
Credentials:LMFT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GOLF TERRACE DR APT 211
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5725
Mailing Address - Country:US
Mailing Address - Phone:904-314-9740
Mailing Address - Fax:
Practice Address - Street 1:27 GOLF TERRACE DR APT 211
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5725
Practice Address - Country:US
Practice Address - Phone:904-314-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-23
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3478101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1982188140Medicaid