Provider Demographics
NPI:1982954038
Name:GIBSON, TARA C (DPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 HOLLOW WOOD LN
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-5019
Mailing Address - Country:US
Mailing Address - Phone:917-804-1020
Mailing Address - Fax:
Practice Address - Street 1:1445 E PUTNAM AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1379
Practice Address - Country:US
Practice Address - Phone:203-983-5748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0341152251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic