Healthcare Provider Details

I. General information

NPI: 1306841267
Provider Name (Legal Business Name): CHERYL DENISE TIBBETTS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 SCOTTS VALLEY DR SUITE D
SCOTTS VALLEY CA
95066-4278
US

IV. Provider business mailing address

4615 SCOTTS VALLEY DR SUITE D
SCOTTS VALLEY CA
95066-4278
US

V. Phone/Fax

Practice location:
  • Phone: 831-438-4478
  • Fax: 831-438-5059
Mailing address:
  • Phone: 831-438-4478
  • Fax: 831-438-5059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number19660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: