Provider Demographics
NPI:1871665729
Name:GIBBONS, TERI LEA (MPT)
Entity Type:Individual
Prefix:MRS
First Name:TERI
Middle Name:LEA
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:
Other - Last Name:CHARLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:261 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2495
Mailing Address - Country:US
Mailing Address - Phone:313-745-1100
Mailing Address - Fax:
Practice Address - Street 1:261 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-745-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006630225100000X
MI5001006630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist