Provider Demographics
NPI:1013415405
Name:GIBSON, JULIET DACAL (EDS)
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:DACAL
Last Name:GIBSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 CHESTNUT AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24416-2621
Mailing Address - Country:US
Mailing Address - Phone:540-261-2887
Mailing Address - Fax:540-261-2967
Practice Address - Street 1:2329 CHESTNUT AVE STE A
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:VA
Practice Address - Zip Code:24416-2621
Practice Address - Country:US
Practice Address - Phone:540-261-2887
Practice Address - Fax:540-261-2967
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000349103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool