Provider Demographics
NPI:1649734997
Name:GIBSON, JUSTIN GEORGE
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GEORGE
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:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:BOKCHITO
Mailing Address - State:OK
Mailing Address - Zip Code:74726-0105
Mailing Address - Country:US
Mailing Address - Phone:580-775-9191
Mailing Address - Fax:
Practice Address - Street 1:100 N 5TH ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4005
Practice Address - Country:US
Practice Address - Phone:580-775-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health