Provider Demographics
NPI:1407043946
Name:TIBBETT, HEATHER DAWN (MCD, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:DAWN
Last Name:TIBBETT
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MANOR ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1936
Mailing Address - Country:US
Mailing Address - Phone:870-739-1600
Mailing Address - Fax:
Practice Address - Street 1:210 MANOR ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1936
Practice Address - Country:US
Practice Address - Phone:870-739-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-28
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP3069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190655721Medicaid