Provider Demographics
NPI:1679517767
Name:HIBBS, DOUGLAS KEVIN (PT)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:KEVIN
Last Name:HIBBS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3428
Mailing Address - Country:US
Mailing Address - Phone:304-752-4443
Mailing Address - Fax:304-752-8802
Practice Address - Street 1:364 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3428
Practice Address - Country:US
Practice Address - Phone:304-752-4443
Practice Address - Fax:304-752-8802
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156387000Medicaid
WV0156387000Medicaid