Provider Demographics
NPI:1194999391
Name:TIBBS, STEPHANIE (OTR/L)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:TIBBS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-6455
Mailing Address - Country:US
Mailing Address - Phone:501-329-8102
Mailing Address - Fax:
Practice Address - Street 1:1700 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-6455
Practice Address - Country:US
Practice Address - Phone:501-329-8102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1641225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175509795Medicaid