Provider Demographics
NPI:1043543465
Name:GIBSON, MICHAEL WAYNE (M ED)
Entity Type:Individual
Prefix:PROF
First Name:MICHAEL
Middle Name:WAYNE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 BRIAN HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-5503
Mailing Address - Country:US
Mailing Address - Phone:713-688-1811
Mailing Address - Fax:713-688-1911
Practice Address - Street 1:4625 NORTH FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-2914
Practice Address - Country:US
Practice Address - Phone:713-697-0776
Practice Address - Fax:713-697-2309
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7635101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1634099 01Medicaid