Provider Demographics
NPI:1801102447
Name:SIDIBE, IBRAHIMA S (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:IBRAHIMA
Middle Name:S
Last Name:SIDIBE
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6555 U S HIGHWAY 98
Mailing Address - Street 2:SUITE A
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8699
Mailing Address - Country:US
Mailing Address - Phone:601-261-0111
Mailing Address - Fax:601-579-9782
Practice Address - Street 1:6555 US 98 WEST
Practice Address - Street 2:SUITE A
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-261-0191
Practice Address - Fax:601-579-9782
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLMT0403225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist