Healthcare Provider Details

I. General information

NPI: 1629501143
Provider Name (Legal Business Name): MAHA TABBARA TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 36TH ST SE
GRAND RAPIDS MI
49508-5580
US

IV. Provider business mailing address

5532 CYPRESS BAY DR
KALAMAZOO MI
49009-7755
US

V. Phone/Fax

Practice location:
  • Phone: 269-965-8078
  • Fax:
Mailing address:
  • Phone: 269-870-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberM188076
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: