Provider Demographics
NPI:1942860424
Name:GIBBONS, MARIE-LULA
Entity Type:Individual
Prefix:
First Name:MARIE-LULA
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19315B 69TH AVE APT 3C
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4006
Mailing Address - Country:US
Mailing Address - Phone:347-561-4519
Mailing Address - Fax:
Practice Address - Street 1:19315B 69TH AVE APT 3C
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-4006
Practice Address - Country:US
Practice Address - Phone:347-561-4519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant