Healthcare Provider Details

I. General information

NPI: 1801503487
Provider Name (Legal Business Name): TABITHA JUSTICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 2ND AVE
CHARLESTON WV
25387-2514
US

IV. Provider business mailing address

1401 CHESTNUT ST
KENOVA WV
25530-1235
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-0586
  • Fax:
Mailing address:
  • Phone: 304-453-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: