Provider Demographics
NPI:1285983262
Name:TIBBETTS, KEITH GORDON (LCPC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:GORDON
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 EMERALD DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444
Mailing Address - Country:US
Mailing Address - Phone:207-307-4505
Mailing Address - Fax:207-941-2955
Practice Address - Street 1:50 EMERALD DRIVE
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444
Practice Address - Country:US
Practice Address - Phone:207-307-4505
Practice Address - Fax:207-941-2955
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3783101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional