Provider Demographics
NPI:1336258573
Name:GIBSON, LIBBY S
Entity Type:Individual
Prefix:MRS
First Name:LIBBY
Middle Name:S
Last Name:GIBSON
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 1:2793 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6288
Mailing Address - Country:US
Mailing Address - Phone:479-973-9686
Mailing Address - Fax:479-582-2746
Practice Address - Street 1:237 E MILSAP DR
Practice Address - Street 2:SUITE 7
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6288
Practice Address - Country:US
Practice Address - Phone:479-582-2740
Practice Address - Fax:479-582-2746
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR554225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X277OtherBCBS