Provider Demographics
NPI:1811521172
Name:GIBSON, KELLY BRUCE (DPT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BRUCE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 ROCKSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2178
Mailing Address - Country:US
Mailing Address - Phone:216-459-2846
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:5520 BROADVIEW RD FRNT
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1606
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty