Provider Demographics
NPI:1003581760
Name:GIBBS, TRACEY LEE (MOT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-9262
Mailing Address - Country:US
Mailing Address - Phone:870-784-3285
Mailing Address - Fax:
Practice Address - Street 1:605 MENA ST
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-3339
Practice Address - Country:US
Practice Address - Phone:479-385-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT2021-017225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist