Provider Demographics
NPI:1710660865
Name:GIBSON, RAEGAN ELIZABETH
Entity Type:Individual
Prefix:
First Name:RAEGAN
Middle Name:ELIZABETH
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 1:7051 NORTH PROMONTORY RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:304-376-0110
Mailing Address - Fax:
Practice Address - Street 1:7051 N PROMONTORY RANCH RD
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4934
Practice Address - Country:US
Practice Address - Phone:304-376-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist