Provider Demographics
NPI:1386863330
Name:GIBSON, GREGORY DAVID
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DAVID
Last Name:GIBSON
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 1:2336 GODDARD PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6362
Practice Address - Street 1:29520 CANVASBACK DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7124
Practice Address - Country:US
Practice Address - Phone:410-822-5007
Practice Address - Fax:410-822-5569
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609500303Medicaid
MD609550001Medicaid
MD609550004Medicaid
MDLM49EAOtherCAREFIRST BCBS GROUP
R968OtherCAREFIRST FEDERAL GROUP
517251OtherUHC MAMSI GROUP
MD609550002Medicaid
MD609500300Medicaid
MD259147000OtherMAGELLAN GROUP
MD609500301Medicaid
MD609550004Medicaid