Healthcare Provider Details

I. General information

NPI: 1366698805
Provider Name (Legal Business Name): TINA MARIE HIBBS M.S.,CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 BUFFALO TRCE
MADISONVILLE KY
42431-8670
US

IV. Provider business mailing address

3065 BUFFALO TRCE
MADISONVILLE KY
42431-8670
US

V. Phone/Fax

Practice location:
  • Phone: 270-836-4727
  • Fax: 270-825-6031
Mailing address:
  • Phone: 270-836-4727
  • Fax: 270-825-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2747
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: