Provider Demographics
NPI:1508394065
Name:GIBSON, ALEX JAMES (SLP)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:JAMES
Last Name:GIBSON
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MIDWESTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-2211
Mailing Address - Country:US
Mailing Address - Phone:940-322-0771
Mailing Address - Fax:940-766-4943
Practice Address - Street 1:1005 MIDWESTERN PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-2211
Practice Address - Country:US
Practice Address - Phone:940-322-0771
Practice Address - Fax:940-766-4943
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist