Provider Demographics
NPI:1962224048
Name:WATERS, TABITHA RENAE
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:RENAE
Last Name:WATERS
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 1:213 PINERIDGE RD # TAYLORA
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AL
Mailing Address - Zip Code:36301-9197
Mailing Address - Country:US
Mailing Address - Phone:334-446-7828
Mailing Address - Fax:
Practice Address - Street 1:213 PINERIDGE RD # TAYLORA
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:AL
Practice Address - Zip Code:36301-9197
Practice Address - Country:US
Practice Address - Phone:334-661-7828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician