Provider Demographics
NPI:1275633760
Name:GIBSON, ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 STERLING ST
Mailing Address - Street 2:SUITE 35
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-1200
Mailing Address - Country:US
Mailing Address - Phone:508-754-6444
Mailing Address - Fax:978-464-5838
Practice Address - Street 1:45 STERLING ST
Practice Address - Street 2:SUITE 35
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1200
Practice Address - Country:US
Practice Address - Phone:508-754-6444
Practice Address - Fax:978-464-5838
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5096103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04788Medicare ID - Type Unspecified