Provider Demographics
NPI:1396587259
Name:DIBBLE, GAVIN CONNOR (DPT)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:CONNOR
Last Name:DIBBLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 POINTE CIR N
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1542
Mailing Address - Country:US
Mailing Address - Phone:631-566-7607
Mailing Address - Fax:
Practice Address - Street 1:1312 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2514
Practice Address - Country:US
Practice Address - Phone:631-732-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NY052589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist