Provider Demographics
NPI:1083751564
Name:GIBNEY, KRISTIE L (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:L
Last Name:GIBNEY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W MAIN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5328
Mailing Address - Country:US
Mailing Address - Phone:253-841-8700
Mailing Address - Fax:
Practice Address - Street 1:214 W MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-5328
Practice Address - Country:US
Practice Address - Phone:253-841-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002965235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist