Healthcare Provider Details

I. General information

NPI: 1003389800
Provider Name (Legal Business Name): LEAH GIBSON MS, OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 FULTON ST E
GRAND RAPIDS MI
49546-1322
US

IV. Provider business mailing address

724 EVELYN ST NE
GRAND RAPIDS MI
49505-4270
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4971
  • Fax:
Mailing address:
  • Phone: 989-239-4934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201008330
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: