Provider Demographics
NPI:1073992772
Name:TIBBETTS, MAXINE (LCMHC)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 LASATER RD
Mailing Address - Street 2:
Mailing Address - City:BUNNLEVEL
Mailing Address - State:NC
Mailing Address - Zip Code:28323-9137
Mailing Address - Country:US
Mailing Address - Phone:910-257-8778
Mailing Address - Fax:
Practice Address - Street 1:749 LASATER RD
Practice Address - Street 2:
Practice Address - City:BUNNLEVEL
Practice Address - State:NC
Practice Address - Zip Code:28323-9137
Practice Address - Country:US
Practice Address - Phone:910-257-8778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NC15327101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1073992772Medicaid