Provider Demographics
NPI:1326581679
Name:GIPSON, KOURTNEY (AT)
Entity type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:GIPSON
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 S DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1504
Mailing Address - Country:US
Mailing Address - Phone:937-643-0893
Mailing Address - Fax:
Practice Address - Street 1:2669 S DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1504
Practice Address - Country:US
Practice Address - Phone:937-643-0893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0043522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer