Provider Demographics
NPI:1366590846
Name:TABB, MICHAEL LEANDER SR
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEANDER
Last Name:TABB
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-4006
Mailing Address - Country:US
Mailing Address - Phone:415-332-6962
Mailing Address - Fax:
Practice Address - Street 1:120 N REDWOOD DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1941
Practice Address - Country:US
Practice Address - Phone:415-473-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health