Provider Demographics
NPI:1275301178
Name:GIBSON, MALIYA
Entity Type:Individual
Prefix:
First Name:MALIYA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MASON
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:324 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TILTONSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43963-1064
Mailing Address - Country:US
Mailing Address - Phone:304-650-1917
Mailing Address - Fax:
Practice Address - Street 1:1 HALLORAN DRIVE
Practice Address - Street 2:
Practice Address - City:ST. CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950
Practice Address - Country:US
Practice Address - Phone:740-296-5743
Practice Address - Fax:740-296-5952
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician