Provider Demographics
NPI:1760917272
Name:GIBSON, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 GLENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23664-1850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5151 BONNEY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4384
Practice Address - Country:US
Practice Address - Phone:757-222-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000185106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst