Provider Demographics
NPI:1164285888
Name:GIBBON, MACKENZIE CATHARINE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:CATHARINE
Last Name:GIBBON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 DR CALVIN JONES HWY
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3105
Mailing Address - Country:US
Mailing Address - Phone:919-673-4246
Mailing Address - Fax:877-828-3925
Practice Address - Street 1:616 DR CALVIN JONES HWY
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3105
Practice Address - Country:US
Practice Address - Phone:919-673-4246
Practice Address - Fax:877-828-3925
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16567225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty