Healthcare Provider Details

I. General information

NPI: 1942188800
Provider Name (Legal Business Name): TABETHA CONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 E OAK ST
FORT BRAGG CA
95437-3610
US

IV. Provider business mailing address

101 N FRANKLIN ST
FORT BRAGG CA
95437-3602
US

V. Phone/Fax

Practice location:
  • Phone: 707-941-0859
  • Fax:
Mailing address:
  • Phone: 707-941-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: