Provider Demographics
NPI:1205825437
Name:GIBSON, MARY PUCKETT (MS, NCC, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:PUCKETT
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 HINTON RD
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2155
Mailing Address - Country:US
Mailing Address - Phone:678-377-2285
Mailing Address - Fax:
Practice Address - Street 1:223 SCENIC HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-5603
Practice Address - Country:US
Practice Address - Phone:770-995-1846
Practice Address - Fax:770-995-6614
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional