Healthcare Provider Details

I. General information

NPI: 1164890075
Provider Name (Legal Business Name): SHONDA TIBBS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 NORRIS RD
BOWLING GREEN KY
42101-8024
US

IV. Provider business mailing address

481 NORRIS RD
BOWLING GREEN KY
42101-8024
US

V. Phone/Fax

Practice location:
  • Phone: 270-792-0262
  • Fax:
Mailing address:
  • Phone: 270-792-0262
  • Fax: 270-904-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7329
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number253280
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7329
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: