Provider Demographics
NPI:1144265190
Name:GIBSON, MITZI A (MSPT)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10014 N RODNEY PARHAM RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-5548
Mailing Address - Country:US
Mailing Address - Phone:501-224-5454
Mailing Address - Fax:501-224-5460
Practice Address - Street 1:10014 N RODNEY PARHAM RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-5548
Practice Address - Country:US
Practice Address - Phone:501-224-5454
Practice Address - Fax:501-224-5460
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143565721Medicaid
ARP00412703OtherMEDICARE RR
AR5T563OtherBLUE CROSS BLUE SHIELD
AR143565721Medicaid