Healthcare Provider Details

I. General information

NPI: 1598239485
Provider Name (Legal Business Name): DALLAS TIBBETTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11902 97TH AVE NE
KIRKLAND WA
98034-1882
US

IV. Provider business mailing address

101 HERON OAKS
ROCKPORT TX
78382-4332
US

V. Phone/Fax

Practice location:
  • Phone: 425-821-4600
  • Fax: 425-821-4622
Mailing address:
  • Phone: 970-261-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60827488
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT134091
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: