Provider Demographics
NPI:1578833596
Name:GIBBONS, BRETT J (DOC OF PHYSICAL THER)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DOC OF PHYSICAL THER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:930 W RALPH HALL PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6664
Mailing Address - Country:US
Mailing Address - Phone:972-771-0999
Mailing Address - Fax:972-771-2281
Practice Address - Street 1:930 W RALPH HALL PKWY STE 120
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6664
Practice Address - Country:US
Practice Address - Phone:972-771-0999
Practice Address - Fax:972-771-2281
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1207866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1207866OtherLICENSE NUMBER