MEDICARE: KACY LEE TIBBETTS DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	4596	OK

General Provider Information

NPI Number	:	1386980241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACY LEE TIBBETTS DPT

Provider Business Mailing Address
First Line	:	700 NW 7TH ST
Second Line	:	SUITE 302
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1212
Country	:	US
Telephone Number	:	405-609-3675
Fax Number	:	800-506-3795

Provider Business Practice Location Address
First Line	:	1507 BROOKWOOD AVE
Second Line	:
City	:	DUNCAN
State	:	OK
Zip	:	73533-1356
Country	:	US
Telephone Number	:	580-252-9159
Fax Number	:	580-255-2158

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2012
Last Update Date	:	01/08/2014

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