Healthcare Provider Details

I. General information

NPI: 1508394065
Provider Name (Legal Business Name): ALEX JAMES GIBSON SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 MIDWESTERN PKWY
WICHITA FALLS TX
76302-2211
US

IV. Provider business mailing address

1005 MIDWESTERN PKWY
WICHITA FALLS TX
76302-2211
US

V. Phone/Fax

Practice location:
  • Phone: 940-322-0771
  • Fax: 940-766-4943
Mailing address:
  • Phone: 940-322-0771
  • Fax: 940-766-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number112617
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: