Healthcare Provider Details

I. General information

NPI: 1891247524
Provider Name (Legal Business Name): CHRISTOPHER TIBBETTS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

IV. Provider business mailing address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-6100
  • Fax: 207-973-6107
Mailing address:
  • Phone: 207-973-6100
  • Fax: 207-973-6107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC16113
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: