Provider Demographics
NPI:1003389800
Name:GIBSON, LEAH (MS, OTRL)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 EVELYN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4270
Mailing Address - Country:US
Mailing Address - Phone:989-239-4934
Mailing Address - Fax:
Practice Address - Street 1:3600 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-1322
Practice Address - Country:US
Practice Address - Phone:616-949-4971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008330225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist