Provider Demographics
NPI:1205001260
Name:ROWE GIBSON, LOLITA MICHELE
Entity Type:Individual
Prefix:
First Name:LOLITA
Middle Name:MICHELE
Last Name:ROWE GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 SW 8TH TER
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-6248
Mailing Address - Country:US
Mailing Address - Phone:816-695-7611
Mailing Address - Fax:
Practice Address - Street 1:3809 SW 8TH TER
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-6248
Practice Address - Country:US
Practice Address - Phone:816-695-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities