Provider Demographics
NPI:1447599816
Name:GIBBS, MELANIE MARIE (LPTA)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MARIE
Last Name:GIBBS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22038 KELLOGG RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:OH
Mailing Address - Zip Code:43522-9718
Mailing Address - Country:US
Mailing Address - Phone:567-204-3313
Mailing Address - Fax:
Practice Address - Street 1:3231 MANLEY RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9680
Practice Address - Country:US
Practice Address - Phone:419-865-1248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.03716225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant