Provider Demographics
NPI:1114382595
Name:GIBSON, CRYSTAL (TLLP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33730 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6302
Mailing Address - Country:US
Mailing Address - Phone:248-830-7541
Mailing Address - Fax:
Practice Address - Street 1:33730 RYAN RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6302
Practice Address - Country:US
Practice Address - Phone:248-830-7541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist