Healthcare Provider Details

I. General information

NPI: 1043533318
Provider Name (Legal Business Name): ROBIN LYNN TIBBALS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SW 1ST AVE
PORTLAND OR
97204-3579
US

IV. Provider business mailing address

228 SW 1ST AVE
PORTLAND OR
97204-3579
US

V. Phone/Fax

Practice location:
  • Phone: 503-213-3745
  • Fax:
Mailing address:
  • Phone: 503-213-3745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16526
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: