Provider Demographics
NPI:1134217904
Name:GIBBY, BRIAN ADAM (OT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ADAM
Last Name:GIBBY
Suffix:
Gender:M
Credentials:OT
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 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:801-314-5220
Mailing Address - Fax:801-314-5221
Practice Address - Street 1:527 W 400 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1916
Practice Address - Country:US
Practice Address - Phone:801-714-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59303064201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6147Medicaid