Provider Demographics
NPI:1093236689
Name:GIBSON, LAURA ISABEL (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ISABEL
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 PALM COVE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-8050
Mailing Address - Country:US
Mailing Address - Phone:407-808-8942
Mailing Address - Fax:
Practice Address - Street 1:7975 LAKE UNDERHILL RD STE 300
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-8205
Practice Address - Country:US
Practice Address - Phone:407-303-6733
Practice Address - Fax:407-303-6715
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6717235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist