Provider Demographics
NPI:1295512093
Name:GIBSON, BROOKE LAUREN (COTA/L)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAUREN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 BOARDTOWN RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-2354
Mailing Address - Country:US
Mailing Address - Phone:478-662-8137
Mailing Address - Fax:
Practice Address - Street 1:114 PENLAND ST
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-0487
Practice Address - Country:US
Practice Address - Phone:706-914-2483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002788224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant