Provider Demographics
NPI:1548621659
Name:GIBSON, TRACI LYNN (MSED)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LYNN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1182 SCARLET QUARRY CIR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9372
Mailing Address - Country:US
Mailing Address - Phone:317-919-1122
Mailing Address - Fax:
Practice Address - Street 1:1182 SCARLET QUARRY CIR
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9372
Practice Address - Country:US
Practice Address - Phone:317-919-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist