Provider Demographics
NPI:1295984912
Name:TIBBETTS, JULIE M (DPT, PT, LAC, LMT)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:DPT, PT, LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4956 WARING RD
Mailing Address - Street 2:STE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120
Mailing Address - Country:US
Mailing Address - Phone:619-618-5780
Mailing Address - Fax:
Practice Address - Street 1:4956 WARING RD
Practice Address - Street 2:STE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120
Practice Address - Country:US
Practice Address - Phone:619-618-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15199171100000X, 171100000X
CAPT34929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-4007507Other26-4007507
CAFM060ZMedicare PIN