Provider Demographics
NPI:1558719443
Name:GIBSON, WANDA (MA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:DARLENE
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:425 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0713
Mailing Address - Country:US
Mailing Address - Phone:270-444-3650
Mailing Address - Fax:
Practice Address - Street 1:425 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-0713
Practice Address - Country:US
Practice Address - Phone:270-444-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker