Provider Demographics
NPI:1205448644
Name:BLACK, TABITHA TAMARA
Entity type:Individual
Prefix:MS
First Name:TABITHA
Middle Name:TAMARA
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6049
Mailing Address - Country:US
Mailing Address - Phone:562-682-0116
Mailing Address - Fax:
Practice Address - Street 1:HARBOR UCLA DMH 1000 W CARSON STREET
Practice Address - Street 2:NUMBER 488
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502
Practice Address - Country:US
Practice Address - Phone:424-306-5737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program