Provider Demographics
NPI:1992164180
Name:GIBBONS, SARITA Y
Entity type:Individual
Prefix:
First Name:SARITA
Middle Name:Y
Last Name:GIBBONS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3538 MICHAEL AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3424
Mailing Address - Country:US
Mailing Address - Phone:616-535-9226
Mailing Address - Fax:
Practice Address - Street 1:3538 MICHAEL AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-3424
Practice Address - Country:US
Practice Address - Phone:616-535-9226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2025-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
MI7501008177172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist