Healthcare Provider Details

I. General information

NPI: 1689164402
Provider Name (Legal Business Name): JOSHUA GEORGE STIBB PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 N LAKEWOOD DR STE 100
COEUR D ALENE ID
83814-2635
US

IV. Provider business mailing address

W10437 COUNTY ROAD G
BEAVER DAM WI
53916-9552
US

V. Phone/Fax

Practice location:
  • Phone: 208-966-4475
  • Fax: 208-966-4476
Mailing address:
  • Phone: 920-319-2396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-8264
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: