Healthcare Provider Details

I. General information

NPI: 1134210131
Provider Name (Legal Business Name): DAVID TIBERIO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 05/19/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 DOG LN UNIT 4249
STORRS MANSFIELD CT
06269-4249
US

IV. Provider business mailing address

PO BOX 34
STORRS MANSFIELD CT
06268-0034
US

V. Phone/Fax

Practice location:
  • Phone: 860-486-8615
  • Fax:
Mailing address:
  • Phone: 860-214-2483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002865
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2272
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT01731
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: