MEDICARE: MRS. DERENDA JEAN GIBBS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	726	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396861381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DERENDA JEAN GIBBS PT

Provider Business Mailing Address
First Line	:	17374 CLEARWATER DR
Second Line	:
City	:	HENSLEY
State	:	AR
Zip	:	72065-8068
Country	:	US
Telephone Number	:	501-888-4850
Fax Number	:

Provider Business Practice Location Address
First Line	:	17374 CLEARWATER DR
Second Line	:
City	:	HENSLEY
State	:	AR
Zip	:	72065-8068
Country	:	US
Telephone Number	:	501-888-4850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/09/2007

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