Provider Demographics
NPI:1548859945
Name:BIBBINS, BLAIRE (MSOT)
Entity type:Individual
Prefix:
First Name:BLAIRE
Middle Name:
Last Name:BIBBINS
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:576 W 900 S STE 106
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84010-8194
Practice Address - Country:US
Practice Address - Phone:801-693-2310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1511225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist