Provider Demographics
NPI:1679307326
Name:GIBSON, MADELINE ELIZABETH (OTR/L)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ELIZABETH
Last Name:GIBSON
Suffix:
Gender:
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 1:4304 BLUE HERON CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-8489
Mailing Address - Country:US
Mailing Address - Phone:843-409-4425
Mailing Address - Fax:
Practice Address - Street 1:1800 2ND LOOP RD STE 12
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-6180
Practice Address - Country:US
Practice Address - Phone:843-407-5236
Practice Address - Fax:843-407-5810
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7326225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH5894Medicaid
SC7326OtherBOARD OF OCCUPATIONAL THERAPY