Provider Demographics
NPI:1629779210
Name:GIBBONS, AGATHA LEE (MS, LBA)
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:LEE
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:MS, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0242
Mailing Address - Country:US
Mailing Address - Phone:801-960-0259
Mailing Address - Fax:
Practice Address - Street 1:32 N 200 W
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-7749
Practice Address - Country:US
Practice Address - Phone:801-960-0259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11923574-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst