Provider Demographics
NPI:1619929536
Name:GIBSON, SIDNEY LANIER JR (LMHC)
Entity Type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:LANIER
Last Name:GIBSON
Suffix:JR
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 W SPRUCE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2346
Mailing Address - Country:US
Mailing Address - Phone:813-636-8811
Mailing Address - Fax:
Practice Address - Street 1:4107 W SPRUCE ST STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2346
Practice Address - Country:US
Practice Address - Phone:813-636-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0000122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007368100Medicaid