Provider Demographics
NPI:1407044878
Name:GIBSON, ROSEMARY (LMT)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6836 MONTAUK CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7825
Mailing Address - Country:US
Mailing Address - Phone:503-705-4641
Mailing Address - Fax:503-598-9726
Practice Address - Street 1:5795 JEAN RD
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5301
Practice Address - Country:US
Practice Address - Phone:503-705-4641
Practice Address - Fax:503-598-9726
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5599225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5599OtherMASSAGE THERAPIST