Provider Demographics
NPI:1528036761
Name:RAINEY GIBSON, ERIC JON
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JON
Last Name:RAINEY GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:JON
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1003 GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-3502
Mailing Address - Country:US
Mailing Address - Phone:515-267-1003
Mailing Address - Fax:515-267-0100
Practice Address - Street 1:1003 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-3502
Practice Address - Country:US
Practice Address - Phone:515-267-1003
Practice Address - Fax:515-267-0100
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAHSP00445103TC0700X, 103TC2200X, 103T00000X
IA00966103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA36432OtherBLUE SHIELD
IA1045898Medicaid
IAIA0134OtherJOHN DEERE HC
J13059Medicare ID - Type Unspecified