Provider Demographics
NPI:1376786152
Name:HIBBARD TIMREK, PAMELA ANN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:HIBBARD TIMREK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:ANN
Other - Last Name:HIBBARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:3816 LINCOLN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48301
Mailing Address - Country:US
Mailing Address - Phone:734-748-9345
Mailing Address - Fax:
Practice Address - Street 1:3816 LINCOLN DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48301
Practice Address - Country:US
Practice Address - Phone:734-748-9345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIASHA09125410235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09125410OtherASHA# LICENSE FOR SPEECH LANGUAGE PATHOLOGY