Provider Demographics
NPI:1306841267
Name:TIBBETTS, CHERYL DENISE (PT)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:DENISE
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 SCOTTS VALLEY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-4278
Mailing Address - Country:US
Mailing Address - Phone:831-438-4478
Mailing Address - Fax:831-438-5059
Practice Address - Street 1:4615 SCOTTS VALLEY DR
Practice Address - Street 2:SUITE D
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4278
Practice Address - Country:US
Practice Address - Phone:831-438-4478
Practice Address - Fax:831-438-5059
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA196602251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT196600Medicare ID - Type UnspecifiedPTIP NUMBER