Provider Demographics
NPI:1255717435
Name:TIBBETT, STARR
Entity type:Individual
Prefix:
First Name:STARR
Middle Name:
Last Name:TIBBETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:3200 JUANIPERO WAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8580
Practice Address - Country:US
Practice Address - Phone:541-505-8426
Practice Address - Fax:541-515-6938
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PROFESSIONALLICENSE101YA0400X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)