Provider Demographics
NPI:1093272676
Name:GIBBONS, IESHA RENEE (AMFT)
Entity Type:Individual
Prefix:MRS
First Name:IESHA
Middle Name:RENEE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:IESHA
Other - Middle Name:
Other - Last Name:NUTTALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMFT
Mailing Address - Street 1:826 N 100 E STE 1A
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:826 N 100 E STE 1A
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1241
Practice Address - Country:US
Practice Address - Phone:801-901-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10493287-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist