Provider Demographics
NPI:1053683599
Name:GIBSON, DONNA L (PT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 POMFRET ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH POMFRET
Mailing Address - State:VT
Mailing Address - Zip Code:05067-0172
Mailing Address - Country:US
Mailing Address - Phone:802-457-2124
Mailing Address - Fax:
Practice Address - Street 1:1806 POMFRET ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH POMFRET
Practice Address - State:VT
Practice Address - Zip Code:05067-0172
Practice Address - Country:US
Practice Address - Phone:802-457-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0000917225100000X
CAPT 15606225100000X
NH0350225100000X
MA11950225100000X
MEPT2045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist