Provider Demographics
NPI:1063922276
Name:MELCOLM, TABATHA (LMHC)
Entity type:Individual
Prefix:MRS
First Name:TABATHA
Middle Name:
Last Name:MELCOLM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 OSCEOLA TRL
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-7149
Mailing Address - Country:US
Mailing Address - Phone:904-502-9883
Mailing Address - Fax:904-490-9037
Practice Address - Street 1:4110 OSCEOLA TRL
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-7149
Practice Address - Country:US
Practice Address - Phone:904-502-9883
Practice Address - Fax:904-490-9037
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16497101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health