Provider Demographics
NPI:1730588088
Name:BETHEL TIBEBU
Entity type:Organization
Organization Name:BETHEL TIBEBU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NA
Authorized Official - Prefix:
Authorized Official - First Name:BETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TIBEBU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-262-4192
Mailing Address - Street 1:21008 ROBINWOOD ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21008 ROBINWOOD ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-5074
Practice Address - Country:US
Practice Address - Phone:734-262-4192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI000000000251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management