Provider Demographics
NPI:1437492865
Name:GIBBS, MICHAEL GEORGE (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:GIBBS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 W 6TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2534
Mailing Address - Country:US
Mailing Address - Phone:336-765-4703
Mailing Address - Fax:336-765-1396
Practice Address - Street 1:2828 MAPLEWOOD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4138
Practice Address - Country:US
Practice Address - Phone:336-765-4703
Practice Address - Fax:336-765-1396
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP16009OtherPHYSICAL THERAPY LICENSEE