Provider Demographics
NPI:1669806436
Name:GIBSON, LAURA NICHOLE (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:NICHOLE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9178 HIGHLAND RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48386-4619
Mailing Address - Country:US
Mailing Address - Phone:248-698-1277
Mailing Address - Fax:248-698-2089
Practice Address - Street 1:9178 HIGHLAND RD
Practice Address - Street 2:SUITE 2
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-4619
Practice Address - Country:US
Practice Address - Phone:248-698-1277
Practice Address - Fax:248-698-2089
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016315225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist