Provider Demographics
NPI:1275992802
Name:GIBBS, CLETUS
Entity Type:Individual
Prefix:
First Name:CLETUS
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 N 13TH ST
Mailing Address - Street 2:APARTMENT 8
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-1433
Mailing Address - Country:US
Mailing Address - Phone:580-210-8215
Mailing Address - Fax:
Practice Address - Street 1:1500 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542
Practice Address - Country:US
Practice Address - Phone:580-335-3320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health