Provider Demographics
NPI:1437451846
Name:GIBBONS, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:2670 COOKS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-5705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2670 COOKS RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-5705
Practice Address - Country:US
Practice Address - Phone:810-223-3946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2018-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst