Provider Demographics
NPI:1548510175
Name:TIBBETTS, PAIGE (LMT)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:TIBBETTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7803 SE THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-1152
Mailing Address - Country:US
Mailing Address - Phone:503-975-3309
Mailing Address - Fax:
Practice Address - Street 1:58147 COLUMBIA RIVER HWY
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6226
Practice Address - Country:US
Practice Address - Phone:503-438-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13984172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist