Provider Demographics
NPI:1679753842
Name:GIBSON, DERRICK COURTNEY (MS LPC)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:COURTNEY
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MS LPC
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Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9815
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:2 CHATEAU LN
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1626
Practice Address - Country:US
Practice Address - Phone:304-736-9662
Practice Address - Fax:304-733-0079
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV1618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1618OtherSTATE LICENSE