Healthcare Provider Details

I. General information

NPI: 1306038104
Provider Name (Legal Business Name): CRISTIE TERESITA TIBBETTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 LAKE TAHOE BLVD
SOUTH LAKE TAHOE CA
96150-6305
US

IV. Provider business mailing address

1900 LAKE TAHOE BLVD
SOUTH LAKE TAHOE CA
96150-6305
US

V. Phone/Fax

Practice location:
  • Phone: 530-307-1170
  • Fax: 530-307-1170
Mailing address:
  • Phone: 530-573-7965
  • Fax: 530-541-0517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: