Basic Information
| Provider Information | |||||||||
| NPI: | 1720487572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | TABETHA | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7446 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924110446 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N PEPPER AVE | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803145 | ||||||||
| FaxNumber: | 9095802165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2014 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.