Healthcare Provider Details

I. General information

NPI: 1407043946
Provider Name (Legal Business Name): HEATHER DAWN TIBBETT MCD, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MANOR ST
MARION AR
72364-1936
US

IV. Provider business mailing address

210 MANOR ST
MARION AR
72364-1936
US

V. Phone/Fax

Practice location:
  • Phone: 870-739-1600
  • Fax:
Mailing address:
  • Phone: 870-739-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP3069
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: