Provider Demographics
NPI:1851661805
Name:GIBSON, TODD ANDREW (PHD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ANDREW
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3463 MAGIC DR STE 255
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2998
Mailing Address - Country:US
Mailing Address - Phone:210-582-5840
Mailing Address - Fax:210-582-5841
Practice Address - Street 1:3463 MAGIC DR STE 255
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2998
Practice Address - Country:US
Practice Address - Phone:210-582-5840
Practice Address - Fax:210-582-5841
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist