Provider Demographics
NPI:1184503401
Name:GIST, THEODORA C
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:C
Last Name:GIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 E JEFFERSON AVE APT 215
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2890
Mailing Address - Country:US
Mailing Address - Phone:313-687-3633
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-687-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker