Provider Demographics
NPI:1679814388
Name:GIBSON, KRISTIN MARIE (CACII, MAC, LPC, LAC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:CACII, MAC, LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:SC
Mailing Address - Zip Code:29706-1524
Mailing Address - Country:US
Mailing Address - Phone:803-377-8111
Mailing Address - Fax:803-581-5380
Practice Address - Street 1:130 HUDSON ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:SC
Practice Address - Zip Code:29706
Practice Address - Country:US
Practice Address - Phone:803-377-8111
Practice Address - Fax:803-581-5380
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC507390101YA0400X
SC31101YA0400X
SC5604101YP2500X
SC1901313101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional