Provider Demographics
NPI:1902394448
Name:GIBSON, GABRIELLE MAE (MS, OTRL)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MAE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:MAE
Other - Last Name:LOBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTRL
Mailing Address - Street 1:1211 GROVE CT
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9697
Mailing Address - Country:US
Mailing Address - Phone:810-588-9741
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-205-4704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009832225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist