Basic Information
| Provider Information | |||||||||
| NPI: | 1831598168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCMAHON | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6320 W UNION HILLS DR | ||||||||
| Address2: | SUITE A265 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233742424 | ||||||||
| FaxNumber: | 6233742619 | ||||||||
| Practice Location | |||||||||
| Address1: | 6320 W UNION HILLS DR | ||||||||
| Address2: | SUITE A265 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853081096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233742424 | ||||||||
| FaxNumber: | 6233742619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2014 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11055 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.