Provider Demographics
NPI:1194159905
Name:GIBSON, MEGAN KIM (OT)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KIM
Last Name:GIBSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17105 FRANCHISE WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8065
Mailing Address - Country:US
Mailing Address - Phone:507-430-6136
Mailing Address - Fax:
Practice Address - Street 1:12400 PORTLAND AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6868
Practice Address - Country:US
Practice Address - Phone:952-898-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104462225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist