Provider Demographics
NPI:1598175622
Name:MILLER-GIBSON, KRISTINA KAYE (DOCTORATE OTD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:KAYE
Last Name:MILLER-GIBSON
Suffix:
Gender:F
Credentials:DOCTORATE OTD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:KAYE
Other - Last Name:ELAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:115 ROCKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9415
Mailing Address - Country:US
Mailing Address - Phone:606-436-5761
Mailing Address - Fax:606-436-5797
Practice Address - Street 1:305 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701
Practice Address - Country:US
Practice Address - Phone:606-435-1741
Practice Address - Fax:606-435-0490
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY131943225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100417520Medicaid