Provider Demographics
NPI:1265002323
Name:DIBACCO, TABITHA ANNE
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:ANNE
Last Name:DIBACCO
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 1:3200 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-2213
Mailing Address - Country:US
Mailing Address - Phone:513-861-3100
Mailing Address - Fax:
Practice Address - Street 1:1000 S FORT THOMAS AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2305
Practice Address - Country:US
Practice Address - Phone:513-861-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08564103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical