Provider Demographics
NPI:1295849685
Name:GIBSON, GARRY WAYNE (LSCSW)
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:WAYNE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:LARNED
Mailing Address - State:KS
Mailing Address - Zip Code:67550-0146
Mailing Address - Country:US
Mailing Address - Phone:620-285-7335
Mailing Address - Fax:
Practice Address - Street 1:610 E GRANT AVE
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KS
Practice Address - Zip Code:67054-2708
Practice Address - Country:US
Practice Address - Phone:620-723-2272
Practice Address - Fax:620-723-3450
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 2641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068993Medicare ID - Type UnspecifiedMEDICARE