Provider Demographics
NPI:1386432359
Name:LI, TABATHA ORISA
Entity type:Individual
Prefix:
First Name:TABATHA
Middle Name:ORISA
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TABATHA
Other - Middle Name:ORISA
Other - Last Name:GRISSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4280 SERGEANT RD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4280 SERGEANT RD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4611
Practice Address - Country:US
Practice Address - Phone:515-207-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician