MEDICARE: AHBRIA CHONTRELLE GIBSON M.S., CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	117382	TX

General Provider Information

NPI Number	:	1750998571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AHBRIA CHONTRELLE GIBSON M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	600 W 6TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-3684
Country	:	US
Telephone Number	:	682-990-6617
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 W 6TH ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-3684
Country	:	US
Telephone Number	:	682-990-6617
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2020
Last Update Date	:	11/10/2023

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