Provider Demographics
NPI:1447722038
Name:EDWARDS, TABITHA
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 OAK ST SE APT A105
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-4702
Mailing Address - Country:US
Mailing Address - Phone:541-971-5078
Mailing Address - Fax:
Practice Address - Street 1:1605 OAK ST SE APT A105
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-4702
Practice Address - Country:US
Practice Address - Phone:541-971-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR410331224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant