Provider Demographics
NPI:1770327868
Name:GIBSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 HICKORY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:CATLETT
Mailing Address - State:VA
Mailing Address - Zip Code:20119-1719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7310 HERITAGE VILLAGE PLZ UNIT 101
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3303
Practice Address - Country:US
Practice Address - Phone:571-248-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557932111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty