Healthcare Provider Details

I. General information

NPI: 1194999391
Provider Name (Legal Business Name): STEPHANIE TIBBS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2008
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 SOUTH BLVD
CONWAY AR
72034-6455
US

IV. Provider business mailing address

1700 SOUTH BLVD
CONWAY AR
72034-6455
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-8102
  • Fax:
Mailing address:
  • Phone: 501-329-8102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1641
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: