Provider Demographics
NPI:1710031976
Name:GIBEAU, EDWARD BERNARD (EDD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:BERNARD
Last Name:GIBEAU
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 N MILLER RD
Mailing Address - Street 2:#110-07
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3619
Mailing Address - Country:US
Mailing Address - Phone:480-773-0823
Mailing Address - Fax:
Practice Address - Street 1:4300 N MILLER RD
Practice Address - Street 2:#110-07
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-3619
Practice Address - Country:US
Practice Address - Phone:480-773-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3542103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ130897Medicare PIN