Healthcare Provider Details

I. General information

NPI: 1265008395
Provider Name (Legal Business Name): MA CAMILLE TABTAB PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2021
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MAIN ST UNIT 555
RUSK TX
75785-1335
US

IV. Provider business mailing address

PO BOX 774
HENDERSON TX
75653-0774
US

V. Phone/Fax

Practice location:
  • Phone: 903-392-9886
  • Fax:
Mailing address:
  • Phone: 903-392-9886
  • Fax: 903-765-7573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1041920
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: