Provider Demographics
NPI:1346792447
Name:GIBSON, DENISE (LLMSW)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3830 LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4345
Mailing Address - Country:US
Mailing Address - Phone:708-466-7118
Mailing Address - Fax:
Practice Address - Street 1:1101 BALL AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5904
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:616-458-5430
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010996891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical