Basic Information
| Provider Information | |||||||||
| NPI: | 1841936911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | OT/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 COMPASS RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600268001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777873422 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4685 CHUMUCKLA HWY | ||||||||
| Address2: | |||||||||
| City: | PACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325711007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8507368412 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XG0600X | OT19341 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology |
No ID Information.