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NPI Code Detail

MEDICARE: TABAN SALEM PH.D.

MEDICARE: TABAN SALEM PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist611103MS

General Provider Information

NPI Number : 1366190423
Entity Type Code : Individual
Provider Name (Legal Business Name) : TABAN SALEM PH.D.
Provider Business Mailing Address
First Line : 3912 GREAVES ST
Second Line :
City : JACKSON
State : MS
Zip : 39206-5711
Country : US
Telephone Number : 636-544-4472
Fax Number :
Provider Business Practice Location Address
First Line : 241 SUNNYBROOK RD
Second Line :
City : RIDGELAND
State : MS
Zip : 39157-2206
Country : US
Telephone Number : 769-231-9414
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/16/2022
Last Update Date : 11/19/2024

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