Provider Demographics
NPI:1013285121
Name:GRESSARD, TABITHA AILLENE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TABITHA
Middle Name:AILLENE
Last Name:GRESSARD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 GLOVER AVE.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2070
Mailing Address - Country:US
Mailing Address - Phone:334-489-4448
Mailing Address - Fax:334-347-2919
Practice Address - Street 1:557 GLOVER AVE.
Practice Address - Street 2:SUITE 3
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2070
Practice Address - Country:US
Practice Address - Phone:334-489-4448
Practice Address - Fax:334-347-2919
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1725103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical