Provider Demographics
NPI:1386861375
Name:GIBSON, KENT DOUGLAS (LISW)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:DOUGLAS
Last Name:GIBSON
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 ARBOLEDA SENDA, NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-275-3134
Mailing Address - Fax:
Practice Address - Street 1:1500VERANDA DR. SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3897
Practice Address - Country:US
Practice Address - Phone:505-994-0229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-39971041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool