Provider Demographics
NPI:1871009225
Name:GIBSON, TARA TRACI (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:TRACI
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WAYMONT CT STE 120
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3412
Mailing Address - Country:US
Mailing Address - Phone:502-759-2444
Mailing Address - Fax:
Practice Address - Street 1:100 WAYMONT CT STE 120
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3412
Practice Address - Country:US
Practice Address - Phone:502-759-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT383512251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology