Provider Demographics
NPI:1447937362
Name:GIBSON, AMY LEIGH
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LEIGH
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7717 CLAREY LN
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-6707
Mailing Address - Country:US
Mailing Address - Phone:804-513-7458
Mailing Address - Fax:
Practice Address - Street 1:12211 KAIN RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5720
Practice Address - Country:US
Practice Address - Phone:804-519-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006206225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist