Provider Demographics
NPI:1013608892
Name:BIBEAU, RYAN (DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BIBEAU
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MATISSE CT
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1632
Mailing Address - Country:US
Mailing Address - Phone:410-903-2004
Mailing Address - Fax:
Practice Address - Street 1:8895 MCGAW RD STE G
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4746
Practice Address - Country:US
Practice Address - Phone:443-441-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist