Healthcare Provider Details

I. General information

NPI: 1326687146
Provider Name (Legal Business Name): MOLLY ANN TIBBETTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 PHOENIX AVE
LOWELL MA
01852-4991
US

IV. Provider business mailing address

177 PIKE ST
TEWKSBURY MA
01876-2547
US

V. Phone/Fax

Practice location:
  • Phone: 978-453-8331
  • Fax:
Mailing address:
  • Phone: 508-847-1154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number13161
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: