Healthcare Provider Details

I. General information

NPI: 1629564109
Provider Name (Legal Business Name): STEVIE JO NICOLE TIBBETTS MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2018
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24030 INDIAN TOWN RD
COURTLAND VA
23837-2371
US

IV. Provider business mailing address

1146 LYNBROOK RD
RUSTBURG VA
24588-3996
US

V. Phone/Fax

Practice location:
  • Phone: 757-812-3288
  • Fax:
Mailing address:
  • Phone: 916-801-4465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119006589
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: