Provider Demographics
NPI:1215544770
Name:KNOX-GIBBS, TERESA EVALYN (MASTERS)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:EVALYN
Last Name:KNOX-GIBBS
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4098 W FRANCES RD
Mailing Address - Street 2:
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-8521
Mailing Address - Country:US
Mailing Address - Phone:810-577-8730
Mailing Address - Fax:
Practice Address - Street 1:1420 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-6208
Practice Address - Country:US
Practice Address - Phone:810-238-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171M00000XOtherEASTER SEALS