Provider Demographics
NPI:1609199603
Name:GIBSON, GLENUAL T (MA, LAC, CFC)
Entity Type:Individual
Prefix:
First Name:GLENUAL
Middle Name:T
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MA, LAC, CFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 E COURT AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4028
Mailing Address - Country:US
Mailing Address - Phone:812-288-8030
Mailing Address - Fax:812-288-8032
Practice Address - Street 1:534 E COURT AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-4028
Practice Address - Country:US
Practice Address - Phone:812-288-8030
Practice Address - Fax:812-288-8032
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INC1041101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)