Healthcare Provider Details

I. General information

NPI: 1497014716
Provider Name (Legal Business Name): KATIE MARIE TIBBLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE MARIE SYDOR

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30508 HOY ST
LIVONIA MI
48154-3654
US

IV. Provider business mailing address

30508 HOY ST
LIVONIA MI
48154-3654
US

V. Phone/Fax

Practice location:
  • Phone: 734-732-6295
  • Fax:
Mailing address:
  • Phone: 734-732-6295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178007205
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: