Provider Demographics
NPI:1134210131
Name:TIBERIO, DAVID (PT)
Entity type:Individual
Prefix:PROF
First Name:DAVID
Middle Name:
Last Name:TIBERIO
Suffix:
Gender:M
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:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-0034
Mailing Address - Country:US
Mailing Address - Phone:860-214-2483
Mailing Address - Fax:
Practice Address - Street 1:14 DOG LN
Practice Address - Street 2:UNIT 4249
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-4249
Practice Address - Country:US
Practice Address - Phone:860-486-8615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002865225100000X
MA2272225100000X
RIPT01731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPT01731OtherPHYSICAL THERAPY LICENSE
CT002865OtherPHYSICAL THERAPY LICENSE
MA2272OtherPHYSICAL THERAPY LICENSE