Healthcare Provider Details

I. General information

NPI: 1154253169
Provider Name (Legal Business Name): MR. WILLIAM TERRENCE TIBER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CALEDONIA ST
LA CROSSE WI
54603-2616
US

IV. Provider business mailing address

14301 EWING AVE S
BURNSVILLE MN
55306-4885
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-5350
  • Fax:
Mailing address:
  • Phone: 952-746-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number7335-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: