Basic Information
| Provider Information | |||||||||
| NPI: | 1205448644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | TAMARA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2158 W PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928046049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626820116 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | HARBOR UCLA DMH 1000 W CARSON STREET | ||||||||
| Address2: | NUMBER 488 | ||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243065737 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2020 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.