Provider Demographics
NPI:1508275470
Name:GIBSON, DANIEL CLIN
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:CLIN
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:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:UT
Mailing Address - Zip Code:84539-0460
Mailing Address - Country:US
Mailing Address - Phone:435-888-4411
Mailing Address - Fax:435-888-2270
Practice Address - Street 1:331 E HIGHWAY 123
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:UT
Practice Address - Zip Code:84539-7725
Practice Address - Country:US
Practice Address - Phone:435-888-4411
Practice Address - Fax:435-888-2270
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT11508443-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator