Provider Demographics
NPI:1104033034
Name:TIBBETTS, JAMES (LADC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HIGHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-5740
Mailing Address - Country:US
Mailing Address - Phone:207-861-3488
Mailing Address - Fax:207-861-3470
Practice Address - Street 1:8 HIGHWOOD ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5740
Practice Address - Country:US
Practice Address - Phone:207-861-3488
Practice Address - Fax:207-861-3470
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1094101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)