Provider Demographics
NPI:1124418850
Name:GIBSON, DONALD L (MHRT-CSP)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MHRT-CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2036
Mailing Address - Country:US
Mailing Address - Phone:207-764-3319
Mailing Address - Fax:207-764-5377
Practice Address - Street 1:1 EDGEMONT DR
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2036
Practice Address - Country:US
Practice Address - Phone:207-764-3319
Practice Address - Fax:207-764-5377
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1124418850Medicaid