Provider Demographics
NPI:1639390495
Name:GIBSON, RENEE L (MSPT)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 WYLIE AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3533
Mailing Address - Country:US
Mailing Address - Phone:406-544-9344
Mailing Address - Fax:406-375-9938
Practice Address - Street 1:336 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-3126
Practice Address - Country:US
Practice Address - Phone:406-375-9034
Practice Address - Fax:406-375-9938
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1639390495Medicaid