Healthcare Provider Details

I. General information

NPI: 1235663006
Provider Name (Legal Business Name): MR. CLYDE EUGENE TIBBETT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 OREGON ST STE 111
REDDING CA
96001-1754
US

IV. Provider business mailing address

1650 OREGON ST STE 111
REDDING CA
96001-1754
US

V. Phone/Fax

Practice location:
  • Phone: 530-962-0307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT113432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: