Provider Demographics
NPI:1417644287
Name:GIBSON, KORINA LEW
Entity Type:Individual
Prefix:
First Name:KORINA
Middle Name:LEW
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 1:2835 NW BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3807
Mailing Address - Country:US
Mailing Address - Phone:510-798-5096
Mailing Address - Fax:
Practice Address - Street 1:2835 NW BRYANT ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3807
Practice Address - Country:US
Practice Address - Phone:510-798-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11737225XP0200X
OR282230225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics