Provider Demographics
NPI:1790064061
Name:GIBSON, DESTINE' C (DPT)
Entity Type:Individual
Prefix:
First Name:DESTINE'
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:DESTINE'
Other - Middle Name:C
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:21315 BRANCHPORT DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-5275
Mailing Address - Country:US
Mailing Address - Phone:832-443-9372
Mailing Address - Fax:281-861-0375
Practice Address - Street 1:21315 BRANCHPORT DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095-5275
Practice Address - Country:US
Practice Address - Phone:832-443-9372
Practice Address - Fax:281-861-0375
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1171880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist