Healthcare Provider Details

I. General information

NPI: 1720479363
Provider Name (Legal Business Name): RENAE MARI TIBBETT BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENAE OLIVAS BCBA

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HMS STAYNER DR
HINGHAM MA
02043-1664
US

IV. Provider business mailing address

112 LARRABEE BLVD
HOWELL NJ
07731-8697
US

V. Phone/Fax

Practice location:
  • Phone: 617-957-6451
  • Fax: 781-385-7324
Mailing address:
  • Phone: 209-471-7962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB# 1-14-15715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: