| Provider / Organization | NPI | Date Certified |
|---|---|---|
| TABITHA DANIELLE MARTIN | 1053909572 | 2021-01-10 |
| Entity Type | Individual |
| Provider Name | Mrs. Tabitha Danielle Martin LCSW |
| Practice Office Address | 10509 N MANCHESTER DR PEORIA, IL US |
| Practice Office Telephone | 8083211792 |
| Mailing Address | 10509 N MANCHESTER DR PEORIA, IL 616158891 US |
| Business Telephone | 8083211792 |
| Code | License No | State |
|---|---|---|
| 1041C0700X PRIMARY | 149022835 | IL |