Provider Demographics
NPI:1710504295
Name:GIBSON, GARRETT D (DPT, ATC)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:D
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W REMINGTON TER
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-8521
Mailing Address - Country:US
Mailing Address - Phone:816-935-1333
Mailing Address - Fax:
Practice Address - Street 1:9053 ESTATE THOMAS
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802
Practice Address - Country:US
Practice Address - Phone:340-779-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist