Provider Demographics
NPI:1902369382
Name:TIBON, BLESILDA BOOC (PT)
Entity Type:Individual
Prefix:
First Name:BLESILDA
Middle Name:BOOC
Last Name:TIBON
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 1:90 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1527
Mailing Address - Country:US
Mailing Address - Phone:517-278-6454
Mailing Address - Fax:
Practice Address - Street 1:90 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1527
Practice Address - Country:US
Practice Address - Phone:517-278-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501007681OtherBOARD OF PHYSICAL THERAPY
MI5501007681OtherPHYSCIAL THERAPY LICENSE