Provider Demographics
NPI:1629446463
Name:GIBSON, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HUCKLEBERRY HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-5664
Mailing Address - Country:US
Mailing Address - Phone:573-735-4631
Mailing Address - Fax:
Practice Address - Street 1:420 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONROE CITY
Practice Address - State:MO
Practice Address - Zip Code:63456-1345
Practice Address - Country:US
Practice Address - Phone:573-735-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024011235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist