Provider Demographics
NPI:1750742243
Name:SUSAN GIBSON
Entity type:Organization
Organization Name:SUSAN GIBSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:FL LMT MA20318
Authorized Official - Phone:772-530-0093
Mailing Address - Street 1:5143 SE BLUE HERON LN
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-3314
Mailing Address - Country:US
Mailing Address - Phone:772-530-0093
Mailing Address - Fax:
Practice Address - Street 1:611 SW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2925
Practice Address - Country:US
Practice Address - Phone:772-530-0093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA20318173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173C00000XOther Service ProvidersReflexologistGroup - Single Specialty