Provider Demographics
NPI:1437728524
Name:GIBSON, ALYSSA MAE ROSE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MAE ROSE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:MAE ROSE
Other - Last Name:YORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 W 900 S
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:IN
Mailing Address - Zip Code:47234-9773
Mailing Address - Country:US
Mailing Address - Phone:317-512-3063
Mailing Address - Fax:317-663-2947
Practice Address - Street 1:120 W JACKSON ST STE B&C
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1295
Practice Address - Country:US
Practice Address - Phone:317-512-3063
Practice Address - Fax:317-663-2947
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-21-48997103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst