Provider Demographics
NPI:1770218604
Name:HIBBITTS, AMANDA (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HIBBITTS
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
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 5036
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5036
Mailing Address - Country:US
Mailing Address - Phone:336-466-0195
Mailing Address - Fax:
Practice Address - Street 1:364 WILLIAMSON RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5916
Practice Address - Country:US
Practice Address - Phone:336-466-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09069225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09069OtherLICENSE/CERTIFICATION