Provider Demographics
NPI:1932288602
Name:GIBSON, CANDICE (PTA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:857 COLLIER RD NW STE 1
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2544
Mailing Address - Country:US
Mailing Address - Phone:404-419-7760
Mailing Address - Fax:404-351-3977
Practice Address - Street 1:857 COLLIER RD NW STE 1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-2544
Practice Address - Country:US
Practice Address - Phone:404-419-7760
Practice Address - Fax:404-351-3977
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002025225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA002025OtherSTATE LISC NUMBER