Provider Demographics
NPI:1386980241
Name:TIBBETTS, KACY LEE (DPT)
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:LEE
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NW 7TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1212
Mailing Address - Country:US
Mailing Address - Phone:405-609-3675
Mailing Address - Fax:800-506-3795
Practice Address - Street 1:1507 BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1356
Practice Address - Country:US
Practice Address - Phone:580-252-9159
Practice Address - Fax:580-255-2158
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist