Healthcare Provider Details

I. General information

NPI: 1558145581
Provider Name (Legal Business Name): ALICIA TIBBS LMFT - SUPERVISEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2519 WINDMILL DR
SPEARFISH SD
57783-9588
US

IV. Provider business mailing address

PO BOX 5
BELLE FOURCHE SD
57717-0005
US

V. Phone/Fax

Practice location:
  • Phone: 605-559-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number11576
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: