Provider Demographics
NPI:1750059176
Name:GIBSON, JOHN ALLEN (BA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 BEAL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9169
Mailing Address - Country:US
Mailing Address - Phone:419-566-0687
Mailing Address - Fax:
Practice Address - Street 1:1552 BEAL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9169
Practice Address - Country:US
Practice Address - Phone:419-566-0687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist