Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 057.001792 | IL |
NPI | 1013268192 |
---|---|
Provider Name | Linda Tibbs |
First Address | Mason City, IL 62664-9600 |
Second Address | Mason City, IL 62664-9600 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2012 |
Last Update Date | 28/09/2012 |