Basic Information
| Provider Information | |||||||||
| NPI: | 1912025297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETIAKA | ||||||||
| FirstName: | TABARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEARNS | ||||||||
| OtherFirstName: | TABARA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3939 ATLANTIC AVE STE 108 | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908073529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622301039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 830 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908134513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622850149 | ||||||||
| FaxNumber: | 5622850156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | LMFT91151 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.