Provider Demographics
NPI:1588817415
Name:GIBSON, JUSTIN TRAVIS (MA LPC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TRAVIS
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CRACKER BARREL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1650
Mailing Address - Country:US
Mailing Address - Phone:304-525-7851
Mailing Address - Fax:304-525-1073
Practice Address - Street 1:3738 TEAYS VALLEY RD STE B
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9705
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-525-1073
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1914101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid
WV0005355002Medicaid