Provider Demographics
NPI:1538478854
Name:TIBBITTS, DIANE GALE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:GALE
Last Name:TIBBITTS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 CARDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6124
Mailing Address - Country:US
Mailing Address - Phone:541-772-7068
Mailing Address - Fax:
Practice Address - Street 1:720 CARDLEY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6124
Practice Address - Country:US
Practice Address - Phone:541-772-7068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCO851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health