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General NPI Number Information
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NPI Number | 1629501143
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Entity Type | Individual
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Provider Name | MAHA TABBARA TLLP
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Gender | Female
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Dates
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Enumeration Date | 04/11/2017
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Last Update Date | 04/11/2017
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Provider Practice Location Address
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Address Line | 1050 36TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-5580
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Country | US
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Telephone | 269-965-8078
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Fax |
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Provider Business Mailing Address
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Address Line | 5532 CYPRESS BAY DR
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City | KALAMAZOO
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State | MI
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Zip | 49009-7755
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Country | US
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Telephone | 269-870-6522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | M188076
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License Number State | MI
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