Provider Demographics
NPI:1720579345
Name:TABO, LIBERTINE MAGALLON
Entity type:Individual
Prefix:
First Name:LIBERTINE
Middle Name:MAGALLON
Last Name:TABO
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 1:8006 GRANDVIEW CT STE 660
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-3813
Mailing Address - Country:US
Mailing Address - Phone:646-541-1840
Mailing Address - Fax:
Practice Address - Street 1:9140 BELVOIR WOODS PKWY
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-2703
Practice Address - Country:US
Practice Address - Phone:703-799-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042510225100000X
DECP032498T225100000X
VA2305213505225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist