=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558258889
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABITHA KEOLANI GONDER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2025
-----------------------------------------------------
Last Update Date | 06/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 BOSQUE BLVD STE 190
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76710-4777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-329-6866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9102 SHINY TOP RANCH LN
-----------------------------------------------------
City | SALADO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76571-6570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-630-7192
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------