Provider Demographics
NPI:1164687711
Name:GIBSON, GWENETTE BERYL
Entity Type:Individual
Prefix:MS
First Name:GWENETTE
Middle Name:BERYL
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 1:581 PARK PLACE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:718-230-4153
Mailing Address - Fax:
Practice Address - Street 1:1401 OLD NORTHERN ROAD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-625-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
003868-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant