Healthcare Provider Details

I. General information

NPI: 1104586528
Provider Name (Legal Business Name): SHELA TIBAUT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 HUNTERS GLEN DR
PLAINSBORO NJ
08536-2824
US

IV. Provider business mailing address

906 HUNTERS GLEN DR
PLAINSBORO NJ
08536-2824
US

V. Phone/Fax

Practice location:
  • Phone: 609-375-6464
  • Fax:
Mailing address:
  • Phone: 609-375-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06036100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: