Provider Demographics
NPI:1225862105
Name:TABB, LEA SIMONE
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:SIMONE
Last Name:TABB
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 1:22277 W 12 MILE RD APT 23
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-4668
Mailing Address - Country:US
Mailing Address - Phone:586-222-2872
Mailing Address - Fax:
Practice Address - Street 1:22277 W 12 MILE RD APT 23
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4668
Practice Address - Country:US
Practice Address - Phone:586-222-2872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-31
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care