Provider Demographics
NPI:1629362728
Name:GIBSON, TAVIS L (DPT)
Entity Type:Individual
Prefix:
First Name:TAVIS
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 ASHLAND CITY RD STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-6455
Mailing Address - Country:US
Mailing Address - Phone:931-472-4203
Mailing Address - Fax:931-329-5373
Practice Address - Street 1:1865 ASHLAND CITY RD STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6455
Practice Address - Country:US
Practice Address - Phone:931-472-4203
Practice Address - Fax:931-329-5373
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare PIN