Provider Demographics
NPI:1053909572
Name:MARTIN, TABITHA DANIELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:DANIELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10509 N MANCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8891
Mailing Address - Country:US
Mailing Address - Phone:808-321-1792
Mailing Address - Fax:
Practice Address - Street 1:10509 N MANCHESTER DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-8891
Practice Address - Country:US
Practice Address - Phone:808-321-1792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490228351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical