Provider Demographics
NPI:1891247912
Name:TIBBITTS, DAELENE SUEANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DAELENE
Middle Name:SUEANN
Last Name:TIBBITTS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DAELENE
Other - Middle Name:SUEANN
Other - Last Name:STRAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1665 E 5TH N
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647
Mailing Address - Country:US
Mailing Address - Phone:208-598-5047
Mailing Address - Fax:
Practice Address - Street 1:1665 E 5TH N
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647
Practice Address - Country:US
Practice Address - Phone:208-598-5047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-4637225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant