Provider Demographics
NPI:1659668903
Name:GIBSON, MONIQUE (MS)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 GRAND ST
Mailing Address - Street 2:2ND FLORR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4800
Mailing Address - Country:US
Mailing Address - Phone:646-938-8008
Mailing Address - Fax:
Practice Address - Street 1:465 GRAND ST
Practice Address - Street 2:2ND FLORR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4800
Practice Address - Country:US
Practice Address - Phone:646-938-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1035S0200X103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool