Healthcare Provider Details

I. General information

NPI: 1508529470
Provider Name (Legal Business Name): DICKSON TABI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3853 ROSECRANS ST
SAN DIEGO CA
92110-3115
US

IV. Provider business mailing address

600 B ST STE 1570
SAN DIEGO CA
92101-4560
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0439
  • Fax:
Mailing address:
  • Phone: 619-615-0439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95258722
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: