Provider Demographics
NPI:1558125245
Name:PETTIBONE, BILLIE JEAN
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:JEAN
Last Name:PETTIBONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1266
Mailing Address - Street 2:
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-1266
Mailing Address - Country:US
Mailing Address - Phone:541-643-4733
Mailing Address - Fax:
Practice Address - Street 1:725 SE CASS AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-4908
Practice Address - Country:US
Practice Address - Phone:541-643-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist