Provider Demographics
NPI:1316324684
Name:WALLS, TABATHA
Entity type:Individual
Prefix:MRS
First Name:TABATHA
Middle Name:
Last Name:WALLS
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 1:420 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:RICHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:43344-9022
Mailing Address - Country:US
Mailing Address - Phone:740-943-1725
Mailing Address - Fax:
Practice Address - Street 1:420 GROVE ST
Practice Address - Street 2:
Practice Address - City:RICHWOOD
Practice Address - State:OH
Practice Address - Zip Code:43344-9022
Practice Address - Country:US
Practice Address - Phone:740-943-1725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHMA1001111103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool