Provider Demographics
NPI:1588858575
Name:GIPSON, BRANDON R (LOTR)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:R
Last Name:GIPSON
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5621 GINNY RD
Mailing Address - Street 2:
Mailing Address - City:KEITHVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71047-8637
Mailing Address - Country:US
Mailing Address - Phone:318-925-9032
Mailing Address - Fax:
Practice Address - Street 1:725 MITCHELL LN
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2149
Practice Address - Country:US
Practice Address - Phone:318-675-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-01
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist