Provider Demographics
NPI:1346597838
Name:HIBBARD, TRACI ANN (LMP)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:ANN
Last Name:HIBBARD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-9587
Mailing Address - Country:US
Mailing Address - Phone:509-773-5633
Mailing Address - Fax:509-773-5844
Practice Address - Street 1:216 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-9587
Practice Address - Country:US
Practice Address - Phone:509-773-5633
Practice Address - Fax:509-773-5844
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60281480225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist