Provider Demographics
NPI:1518041698
Name:GIBSON, PINKIE (PTA)
Entity Type:Individual
Prefix:
First Name:PINKIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 OLD WHISKEY RD N
Mailing Address - Street 2:
Mailing Address - City:NEW ELLENTON
Mailing Address - State:SC
Mailing Address - Zip Code:29809-2602
Mailing Address - Country:US
Mailing Address - Phone:803-652-3829
Mailing Address - Fax:
Practice Address - Street 1:690 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6348
Practice Address - Country:US
Practice Address - Phone:803-648-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1619225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant