Provider Demographics
NPI:1467540799
Name:GIBSON, KAREN A (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21343 BASE RD
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-8062
Mailing Address - Country:US
Mailing Address - Phone:406-394-2264
Mailing Address - Fax:406-265-2670
Practice Address - Street 1:2229 5TH AVE
Practice Address - Street 2:EAST WING SUITE 208
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-5217
Practice Address - Country:US
Practice Address - Phone:406-945-1328
Practice Address - Fax:406-265-2670
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0532559Medicaid
MT660840Medicare UPIN