Provider Demographics
NPI:1225204688
Name:GIBSON, ROBERT A (CSAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 N US HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0726
Mailing Address - Country:US
Mailing Address - Phone:608-757-5215
Mailing Address - Fax:
Practice Address - Street 1:3506 N US HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0726
Practice Address - Country:US
Practice Address - Phone:608-757-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2063-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)