Provider Demographics
NPI:1588014625
Name:GIBSON, AMY (MOT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 AIRWAYS PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5885
Mailing Address - Country:US
Mailing Address - Phone:662-349-8787
Mailing Address - Fax:662-349-8757
Practice Address - Street 1:12311 ASHLEY DR STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2950
Practice Address - Country:US
Practice Address - Phone:228-357-5253
Practice Address - Fax:662-349-8757
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2607225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics