Provider Demographics
NPI:1407302482
Name:GIBSON, JULIE M
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
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 1:4895 MCCONNELL EAST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44470-9584
Mailing Address - Country:US
Mailing Address - Phone:330-718-1605
Mailing Address - Fax:
Practice Address - Street 1:4895 MCCONNELL EAST RD
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:44470-9584
Practice Address - Country:US
Practice Address - Phone:330-718-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer