Provider Demographics
NPI:1891829388
Name:GIBBONS, CLAYTON ADAM (PT)
Entity Type:Individual
Prefix:
First Name:CLAYTON
Middle Name:ADAM
Last Name:GIBBONS
Suffix:
Gender:M
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:PO BOX 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2000
Mailing Address - Fax:
Practice Address - Street 1:852 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2406
Practice Address - Country:US
Practice Address - Phone:360-501-3750
Practice Address - Fax:360-501-3755
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4563225100000X
WAPT60174534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist