Provider Demographics
NPI:1689214835
Name:GIBSON, QUORDRIC C
Entity Type:Individual
Prefix:
First Name:QUORDRIC
Middle Name:C
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 1:8425 COEBURN ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-7204
Mailing Address - Country:US
Mailing Address - Phone:601-918-3055
Mailing Address - Fax:
Practice Address - Street 1:610 BERCUT DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-0115
Practice Address - Country:US
Practice Address - Phone:916-443-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician