Healthcare Provider Details

I. General information

NPI: 1578637427
Provider Name (Legal Business Name): AMANDA TIBBETTS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MIAMI RD
FT LAUDERDALE FL
33316-2933
US

IV. Provider business mailing address

1919 VAN BUREN ST APT 218
HOLLYWOOD FL
33020-7810
US

V. Phone/Fax

Practice location:
  • Phone: 951-523-5673
  • Fax: 954-467-9580
Mailing address:
  • Phone: 561-704-7588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT19284
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: