Provider Demographics
NPI:1114372232
Name:GIBSON, MARIS
Entity Type:Individual
Prefix:
First Name:MARIS
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S.W. 150THST
Mailing Address - Street 2:#110
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166
Mailing Address - Country:US
Mailing Address - Phone:206-306-3400
Mailing Address - Fax:
Practice Address - Street 1:801 S.W. 150THST
Practice Address - Street 2:#110
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166
Practice Address - Country:US
Practice Address - Phone:206-306-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005228225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist