Healthcare Provider Details

I. General information

NPI: 1407762164
Provider Name (Legal Business Name): EDWARD GIBSON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 MCCLELLAN HWY
HARTS WV
25524-7010
US

IV. Provider business mailing address

PO BOX 111
HARTS WV
25524-0111
US

V. Phone/Fax

Practice location:
  • Phone: 304-533-7261
  • Fax:
Mailing address:
  • Phone: 304-533-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2008-2390
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: