Provider Demographics
NPI:1659545507
Name:GIBSON, SUSAN H (PT)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:H
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1939
Mailing Address - Country:US
Mailing Address - Phone:217-762-3914
Mailing Address - Fax:
Practice Address - Street 1:1304 W BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-2035
Practice Address - Country:US
Practice Address - Phone:217-359-0287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700030932251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics