=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013608892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN BIBEAU DPT, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8895 MCGAW RD STE G
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-4746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-441-0616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1701 MATISSE CT
-----------------------------------------------------
City | SEVERN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21144-1632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-903-2004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------