Provider Demographics
NPI:1730217225
Name:GIBBENS, LINDA I (ATC, LAT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:I
Last Name:GIBBENS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 LINFIELD PL
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5197
Mailing Address - Country:US
Mailing Address - Phone:208-454-8001
Mailing Address - Fax:208-454-8001
Practice Address - Street 1:2112 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4432
Practice Address - Country:US
Practice Address - Phone:208-459-5873
Practice Address - Fax:208-459-5854
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer