=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790091502
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABITHA WINESBERRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2010
-----------------------------------------------------
Last Update Date | 01/20/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 454 LAS GALLINAS AVE # 1065
-----------------------------------------------------
City | SAN RAFAEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94903-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-566-4257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 S KINNELOA AVE STE 200
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-3853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-844-3033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 100620
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------