Healthcare Provider Details

I. General information

NPI: 1912025297
Provider Name (Legal Business Name): TABARA ETIAKA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TABARA HEARNS LMFT

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 ATLANTIC AVE
LONG BEACH CA
90813-4513
US

IV. Provider business mailing address

3939 ATLANTIC AVE STE 108
LONG BEACH CA
90807-3529
US

V. Phone/Fax

Practice location:
  • Phone: 562-285-0149
  • Fax: 562-285-0156
Mailing address:
  • Phone: 562-230-1039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT91151
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: