Provider Demographics
NPI:1629761549
Name:GIBSON, ANTHONY E
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:E
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4516 WILLOW ROCK LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4332
Mailing Address - Country:US
Mailing Address - Phone:817-909-5157
Mailing Address - Fax:
Practice Address - Street 1:2451 W GRAPEVINE MILLS CIR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-2096
Practice Address - Country:US
Practice Address - Phone:682-390-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X, 172V00000X, 251K00000X, 261QC1500X, 261QM0855X, 374700000X, 261QH0100X, 3747P1801X, 385H00000X, 385HR2055X, 106S00000X
TX169230772871261QM0801X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No251K00000XAgenciesPublic Health or Welfare
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No374700000XNursing Service Related ProvidersTechnician
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician