Provider Demographics
NPI:1558258889
Name:GONDER, TABITHA KEOLANI
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:KEOLANI
Last Name:GONDER
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 1:9102 SHINY TOP RANCH LN
Mailing Address - Street 2:
Mailing Address - City:SALADO
Mailing Address - State:TX
Mailing Address - Zip Code:76571-6570
Mailing Address - Country:US
Mailing Address - Phone:254-630-7192
Mailing Address - Fax:
Practice Address - Street 1:5301 BOSQUE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4777
Practice Address - Country:US
Practice Address - Phone:254-329-6866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst