Healthcare Provider Details

I. General information

NPI: 1598163511
Provider Name (Legal Business Name): STACI TIBBS WILSON OTR, MOT, CHES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13212 LONE CREEK LN
PEARLAND TX
77584-3476
US

IV. Provider business mailing address

11601 SHADOW CREEK PKWY STE 111-216
PEARLAND TX
77584-7283
US

V. Phone/Fax

Practice location:
  • Phone: 713-280-3663
  • Fax: 855-710-7269
Mailing address:
  • Phone: 713-280-3663
  • Fax: 855-710-7269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number112297
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: