Healthcare Provider Details

I. General information

NPI: 1093409674
Provider Name (Legal Business Name): ANGEL S GIBSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ESSEX FARMS DR
CHARLESTON SC
29414-6696
US

IV. Provider business mailing address

1114 FLYWAY RD
SUMMERVILLE SC
29483-8021
US

V. Phone/Fax

Practice location:
  • Phone: 843-779-1685
  • Fax:
Mailing address:
  • Phone: 803-316-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5174
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5174
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: