Provider Demographics
NPI:1376186205
Name:GIBSON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
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 1:145 LINKS LN
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-6917
Mailing Address - Country:US
Mailing Address - Phone:817-223-0540
Mailing Address - Fax:
Practice Address - Street 1:700 S BOWIE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5140
Practice Address - Country:US
Practice Address - Phone:817-594-2715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1323240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist