Provider Demographics
NPI:1326086885
Name:GARAY GIBBS, MARY ANGELIE ALCALA (RPT)
Entity Type:Individual
Prefix:
First Name:MARY ANGELIE
Middle Name:ALCALA
Last Name:GARAY GIBBS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E HWY 50 # 129
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3164
Mailing Address - Country:US
Mailing Address - Phone:352-396-0952
Mailing Address - Fax:407-378-4154
Practice Address - Street 1:3721 S HIGHWAY 27
Practice Address - Street 2:B
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-255-6130
Practice Address - Fax:407-378-4154
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT58882251G0304X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4398900Medicaid