Provider Demographics
NPI:1568117166
Name:GIBSON, TINA CASANDRA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:CASANDRA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9135 58TH DR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9188
Mailing Address - Country:US
Mailing Address - Phone:941-248-7985
Mailing Address - Fax:
Practice Address - Street 1:9135 58TH DR E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-9188
Practice Address - Country:US
Practice Address - Phone:941-248-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician