Provider Demographics
NPI:1275396525
Name:GIBSON, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name: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 1:30380 COUNTY ROAD 6
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-9514
Mailing Address - Country:US
Mailing Address - Phone:574-343-2001
Mailing Address - Fax:
Practice Address - Street 1:30380 COUNTY ROAD 6
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-9514
Practice Address - Country:US
Practice Address - Phone:574-343-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician