Basic Information
| Provider Information | |||||||||
| NPI: | 1306192679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NABULSI | ||||||||
| FirstName: | TAREQ | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 849 KELLOGG AVE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087557960 | ||||||||
| FaxNumber: | 6087557873 | ||||||||
| Practice Location | |||||||||
| Address1: | 11741 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906703681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628010318 | ||||||||
| FaxNumber: | 5629493642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4087 | WI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 167G00000X | PT40247 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
ID Information
| ID | Type | State | Issuer | Description | PT40247 | 01 | CA | LICENSED PSYCHIATRIC TECHNICIAN | OTHER |