MEDICARE: DESTINE' C GIBSON DPT

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	225100000X	Physical Therapist	1171880	TX

General Provider Information

NPI Number	:	1790064061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINE' C GIBSON DPT

Provider Business Mailing Address
First Line	:	21315 BRANCHPORT DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77095-5275
Country	:	US
Telephone Number	:	832-443-9372
Fax Number	:	281-861-0375

Provider Business Practice Location Address
First Line	:	21315 BRANCHPORT DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77095-5275
Country	:	US
Telephone Number	:	832-443-9372
Fax Number	:	281-861-0375

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

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	08/25/2020

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Directions to “ DESTINE' C GIBSON DPT” Practice Location

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