Provider Demographics
NPI:1710186309
Name:GIBSON, STEPHANIE ANN (LMP)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 B ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4003
Mailing Address - Country:US
Mailing Address - Phone:206-719-7002
Mailing Address - Fax:253-929-6683
Practice Address - Street 1:515 B ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4003
Practice Address - Country:US
Practice Address - Phone:253-929-8365
Practice Address - Fax:253-929-6683
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017523225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist