Healthcare Provider Details

I. General information

NPI: 1306405451
Provider Name (Legal Business Name): JULIE ELISE TIBBETTS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JULIE TIBBETTS TORRES

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615B MIKE PADGETT HWY
AUGUSTA GA
30906-3898
US

IV. Provider business mailing address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

V. Phone/Fax

Practice location:
  • Phone: 229-326-0543
  • Fax:
Mailing address:
  • Phone: 229-985-4815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10147
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: