Provider Demographics
NPI:1356819700
Name:GIBBS, MATTHEW I
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:I
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43968-1031
Mailing Address - Country:US
Mailing Address - Phone:330-383-6256
Mailing Address - Fax:
Practice Address - Street 1:1704 VILLAGE PARK DR
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2401
Practice Address - Country:US
Practice Address - Phone:803-534-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPT.9197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist