MEDICARE: TABETHA VICTORIA ELIE PMHNP

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	2080P0006X	Developmental - Behavioral Pediatrics Physician	1169630	TX

General Provider Information

NPI Number	:	1891527545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABETHA VICTORIA ELIE PMHNP

Provider Business Mailing Address
First Line	:	2785 GULF FWY S STE 2.200
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4979
Country	:	US
Telephone Number	:	409-772-3695
Fax Number	:

Provider Business Practice Location Address
First Line	:	2785 GULF FWY S STE 2.200
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4979
Country	:	US
Telephone Number	:	409-772-3695
Fax Number	:

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

Provider Enumeration Date	:	08/19/2024
Last Update Date	:	12/10/2025

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