Provider Demographics
NPI:1740428051
Name:GIBERSON, STACY L (MHRT-CSP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:GIBERSON
Suffix:
Gender:F
Credentials:MHRT-CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WESLEYAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04742-2010
Mailing Address - Country:US
Mailing Address - Phone:207-473-9285
Mailing Address - Fax:207-473-9403
Practice Address - Street 1:8 WESLEYAN ST
Practice Address - Street 2:
Practice Address - City:FORT FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04742-2010
Practice Address - Country:US
Practice Address - Phone:207-473-9285
Practice Address - Fax:207-473-9403
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103850000OtherMAINECARE