Provider Demographics
NPI:1134133374
Name:GIBSON, DAVID (LICSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1655
Mailing Address - Country:US
Mailing Address - Phone:651-216-8899
Mailing Address - Fax:
Practice Address - Street 1:821 RAYMOND AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1509
Practice Address - Country:US
Practice Address - Phone:651-216-8899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-51344OtherUBH
MN1025840OtherP1
MN123775OtherUC
MN12D53GIOtherBCBS
MN46411OtherHP
MN475526000Medicaid