Provider Demographics
NPI:1396861381
Name:GIBBS, DERENDA JEAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:DERENDA
Middle Name:JEAN
Last Name:GIBBS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17374 CLEARWATER DR
Mailing Address - Street 2:
Mailing Address - City:HENSLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72065-8068
Mailing Address - Country:US
Mailing Address - Phone:501-888-4850
Mailing Address - Fax:
Practice Address - Street 1:17374 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:HENSLEY
Practice Address - State:AR
Practice Address - Zip Code:72065-8068
Practice Address - Country:US
Practice Address - Phone:501-888-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist