Provider Demographics
NPI:1245949791
Name:GIBSON, MICHELLE RENE' (COTA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENE'
Last Name:GIBSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CREEKVIEW LN
Mailing Address - Street 2:
Mailing Address - City:RINEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40162-9513
Mailing Address - Country:US
Mailing Address - Phone:270-735-6839
Mailing Address - Fax:
Practice Address - Street 1:225 SAINT JOHN RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2918
Practice Address - Country:US
Practice Address - Phone:270-769-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003697A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant