Provider Demographics
NPI:1114190667
Name:GIBSON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E 120TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3052
Mailing Address - Country:US
Mailing Address - Phone:310-668-5150
Mailing Address - Fax:
Practice Address - Street 1:8132 FIRESTONE BLVD # 272
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4231
Practice Address - Country:US
Practice Address - Phone:562-756-7546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23156101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health