Provider Demographics
NPI:1881670198
Name:MCKIBBEN, CARLA K (PT)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:K
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74B CENTENNIAL LOOP
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7918
Mailing Address - Country:US
Mailing Address - Phone:541-686-3791
Mailing Address - Fax:541-686-3795
Practice Address - Street 1:74B CENTENNIAL LOOP
Practice Address - Street 2:SUITE 300
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7918
Practice Address - Country:US
Practice Address - Phone:541-686-3791
Practice Address - Fax:541-686-3795
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278721Medicaid
ORR105765Medicare PIN