Healthcare Provider Details

I. General information

NPI: 1740517044
Provider Name (Legal Business Name): GIBSON P. GELLADUGA OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8422 BROMPTON PLACE DR
HOUSTON TX
77083-5223
US

IV. Provider business mailing address

8422 BROMPTON PLACE DR
HOUSTON TX
77083-5223
US

V. Phone/Fax

Practice location:
  • Phone: 832-466-8686
  • Fax:
Mailing address:
  • Phone: 832-466-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number111611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: