Provider Demographics
NPI:1366452336
Name:DAILEY-GIBSON, DIANNE L (LMSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:L
Last Name:DAILEY-GIBSON
Suffix:
Gender:F
Credentials:LMSW, PHD
Other - Prefix:MRS
Other - First Name:DIANNE
Other - Middle Name:L
Other - Last Name:DAILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:5462 LAHRING RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8918
Mailing Address - Country:US
Mailing Address - Phone:810-265-5698
Mailing Address - Fax:810-735-9473
Practice Address - Street 1:5462 LAHRING RD
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8918
Practice Address - Country:US
Practice Address - Phone:810-265-5698
Practice Address - Fax:810-735-9473
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801003049104100000X, 1041C0700X
MI4101006010106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID 421 143 564 290OtherDRIVERS LICENSE