Provider Demographics
NPI:1528361805
Name:TIBBETTS, BRENDA L
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:DIMITROPOLIS/BRESSEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:170 MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:MONSON
Mailing Address - State:MA
Mailing Address - Zip Code:01057-1353
Mailing Address - Country:US
Mailing Address - Phone:413-267-4200
Mailing Address - Fax:413-267-4200
Practice Address - Street 1:170 MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:MONSON
Practice Address - State:MA
Practice Address - Zip Code:01057-1353
Practice Address - Country:US
Practice Address - Phone:413-267-4200
Practice Address - Fax:413-267-4200
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5499156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician