Healthcare Provider Details

I. General information

NPI: 1548654395
Provider Name (Legal Business Name): ALICIA TIBBS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5774 KINGSGATE DR APT D
ORLANDO FL
32839-4243
US

IV. Provider business mailing address

5774 KINGSGATE DR APT D
ORLANDO FL
32839-4243
US

V. Phone/Fax

Practice location:
  • Phone: 352-615-5046
  • Fax:
Mailing address:
  • Phone: 352-615-5046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA75544
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: