Provider Demographics
NPI:1639454259
Name:TIBOLLO, GREGORY (MS,CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:TIBOLLO
Suffix:
Gender:M
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-4009
Mailing Address - Country:US
Mailing Address - Phone:716-807-3700
Mailing Address - Fax:
Practice Address - Street 1:175 HUMPHREY ST
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-4009
Practice Address - Country:US
Practice Address - Phone:716-807-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011748-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist