Provider Demographics
NPI:1114485257
Name:GIBSON, ERIC KEVEN (NO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:KEVEN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:NO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 BUFFALO TRL
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-9454
Mailing Address - Country:US
Mailing Address - Phone:310-877-0774
Mailing Address - Fax:
Practice Address - Street 1:4301 BUFFALO TRL
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:CO
Practice Address - Zip Code:80620-9454
Practice Address - Country:US
Practice Address - Phone:310-877-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO2137347793Medicaid