Provider Demographics
NPI:1619854502
Name:GIBSON, CLARENCE
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 SILVER PARK DR APT 1A
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-2939
Mailing Address - Country:US
Mailing Address - Phone:202-729-0682
Mailing Address - Fax:
Practice Address - Street 1:2701 NEABSCO COMMON PL APT 127
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-4185
Practice Address - Country:US
Practice Address - Phone:202-729-0682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist