=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518308212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABATHA LYNN TITSWORTH M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2013
-----------------------------------------------------
Last Update Date | 07/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 FERRARI SUITE 100
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91764-5030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-484-2848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15450 NISQUALLI RD APT. O-204
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92395-8535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-360-5833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-13-14090
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------