MEDICARE: TABITHA DENNY

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
1	1041C0700X	Clinical Social Worker	M-10426	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M-10426	OTHER	NM	NONE

General Provider Information

NPI Number	:	1447723622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA DENNY

Provider Business Mailing Address
First Line	:	2105 S PENNSYLVANIA AVE UNIT B
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88203-4157
Country	:	US
Telephone Number	:	919-255-0136
Fax Number	:

Provider Business Practice Location Address
First Line	:	613 W 2ND ST STE 4
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88201-4671
Country	:	US
Telephone Number	:	919-255-0136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2019
Last Update Date	:	01/10/2019

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Directions to “ TABITHA DENNY ” Practice Location

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