Basic Information
| Provider Information | |||||||||
| NPI: | 1386773638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUCKWORTH | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | YVETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LISW-SUPV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3661 THOUSAND OAKS DR | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320654245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045661883 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | LAKE CITY VA MEDICAL CENTER | ||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 11/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S0021568 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | I0700249 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.