Provider Demographics
NPI:1174175731
Name:GIBSON, STEPHANIE SAMANTHA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:SAMANTHA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6397 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-3473
Mailing Address - Fax:
Practice Address - Street 1:5310 MATT HWY STE 105
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-8611
Practice Address - Country:US
Practice Address - Phone:470-239-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007302225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist