Provider Demographics
NPI:1053003327
Name:TIBBS, MICHAEL RAY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:TIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 HOCUS POCUS PL
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-3502
Mailing Address - Country:US
Mailing Address - Phone:702-683-1334
Mailing Address - Fax:
Practice Address - Street 1:5635 KANSAS AVE # 225
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-1226
Practice Address - Country:US
Practice Address - Phone:140-296-0978
Practice Address - Fax:402-227-6491
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty