Provider Demographics
NPI:1194437319
Name:TIBBS, PAULA MISCHELLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:MISCHELLE
Last Name:TIBBS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MISCHELLE
Other - Middle Name:
Other - Last Name:TIBBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:21292 COUNTY ROAD 306
Mailing Address - Street 2:
Mailing Address - City:ORAN
Mailing Address - State:MO
Mailing Address - Zip Code:63771-8248
Mailing Address - Country:US
Mailing Address - Phone:573-429-0161
Mailing Address - Fax:
Practice Address - Street 1:710 GLENN DR
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-3926
Practice Address - Country:US
Practice Address - Phone:573-472-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009013463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist