Provider Demographics
NPI:1194930867
Name:GIBSON, TRACY (DI)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 TORI TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:WEST PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42086-9859
Mailing Address - Country:US
Mailing Address - Phone:270-562-2065
Mailing Address - Fax:270-534-5036
Practice Address - Street 1:3345 TORI TRAIL LN
Practice Address - Street 2:
Practice Address - City:WEST PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42086-9859
Practice Address - Country:US
Practice Address - Phone:270-562-2065
Practice Address - Fax:270-534-5036
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist