Provider Demographics
NPI:1689730434
Name:TIBBETTS, STEVEN P (LICSW)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:P
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 14TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3644
Mailing Address - Country:US
Mailing Address - Phone:612-823-1031
Mailing Address - Fax:612-827-8182
Practice Address - Street 1:4633 14TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3644
Practice Address - Country:US
Practice Address - Phone:612-823-1031
Practice Address - Fax:612-827-8182
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN129141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN03Q12HEOtherBCBS