Provider Demographics
NPI:1588259238
Name:PENN-TABOR, TIA CHALISE
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:CHALISE
Last Name:PENN-TABOR
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 1:112 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-153537106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician