Provider Demographics
NPI:1366190423
Name:SALEM, TABAN (PHD)
Entity type:Individual
Prefix:
First Name:TABAN
Middle Name:
Last Name:SALEM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 GREAVES ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5711
Mailing Address - Country:US
Mailing Address - Phone:636-544-4472
Mailing Address - Fax:
Practice Address - Street 1:241 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2206
Practice Address - Country:US
Practice Address - Phone:769-231-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS611103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical