Healthcare Provider Details

I. General information

NPI: 1891247912
Provider Name (Legal Business Name): DAELENE SUEANN TIBBITTS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DAELENE SUEANN STRAW

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1665 E 5TH N
MOUNTAIN HOME ID
83647
US

IV. Provider business mailing address

1665 E 5TH N
MOUNTAIN HOME ID
83647
US

V. Phone/Fax

Practice location:
  • Phone: 208-598-5047
  • Fax:
Mailing address:
  • Phone: 208-598-5047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-4637
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: