Provider Demographics
NPI:1861153421
Name:GIBSON, AMY M (CMT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:M
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:244 RIDGE RD.
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449
Mailing Address - Country:US
Mailing Address - Phone:805-534-3808
Mailing Address - Fax:
Practice Address - Street 1:244 RIDGE RD.
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449
Practice Address - Country:US
Practice Address - Phone:805-534-3808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88076225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist