Provider Demographics
NPI:1629536396
Name:GIBSON, LAURA ELIZABETH (CRC, T-LMCH)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CRC, T-LMCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 URBANDALE AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-2661
Mailing Address - Country:US
Mailing Address - Phone:515-669-8111
Mailing Address - Fax:
Practice Address - Street 1:4910 URBANDALE AVE STE 304
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-2661
Practice Address - Country:US
Practice Address - Phone:515-669-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084646101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor