Provider Demographics
NPI:1457804213
Name:GIBSON, MICHAELA ADRIANNA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MICHAELA
Middle Name:ADRIANNA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 FREDONIA-STOCKTON ROAD
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063
Mailing Address - Country:US
Mailing Address - Phone:716-672-4371
Mailing Address - Fax:
Practice Address - Street 1:9520 FREDONIA-STOCKTON ROAD
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063
Practice Address - Country:US
Practice Address - Phone:716-672-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020739225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist