Healthcare Provider Details

I. General information

NPI: 1174022990
Provider Name (Legal Business Name): NICHOLAS RYAN BIBEAU DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD STE 210
APACHE JUNCTION AZ
85119-6405
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-0877
  • Fax: 480-983-3172
Mailing address:
  • Phone: 616-356-5000
  • Fax: 616-356-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-30635
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: