Provider Demographics
NPI:1609347285
Name:GIBSON, LUWILLIS (PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:LUWILLIS
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-1114
Mailing Address - Country:US
Mailing Address - Phone:231-343-2753
Mailing Address - Fax:
Practice Address - Street 1:1014 DUNHAM ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2659
Practice Address - Country:US
Practice Address - Phone:231-343-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No175T00000XOther Service ProvidersPeer Specialist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251X00000XAgenciesSupports Brokerage
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility