Provider Demographics
NPI:1700930872
Name:KONTJE-GIBBS, FAE E (LIC AC)
Entity Type:Individual
Prefix:
First Name:FAE
Middle Name:E
Last Name:KONTJE-GIBBS
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 N WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5436
Mailing Address - Country:US
Mailing Address - Phone:508-693-6993
Mailing Address - Fax:
Practice Address - Street 1:86 N WILLIAM ST
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5436
Practice Address - Country:US
Practice Address - Phone:508-693-6993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217675171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist