Provider Demographics
NPI:1437636297
Name:ADEBISI, MARIE GIBSON (MARIE)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:GIBSON
Last Name:ADEBISI
Suffix:
Gender:F
Credentials:MARIE
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2086
Practice Address - Country:US
Practice Address - Phone:218-724-3122
Practice Address - Fax:218-606-1291
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN101YM0800XOtherWORK ISSUED