Provider Demographics
NPI:1770842676
Name:GIBBS, THERESA LORRAINE
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LORRAINE
Last Name:GIBBS
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 1:7760 MYERS RD
Mailing Address - Street 2:
Mailing Address - City:KIRKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13082-9779
Mailing Address - Country:US
Mailing Address - Phone:315-656-2574
Mailing Address - Fax:
Practice Address - Street 1:138 NORTH COURT ST
Practice Address - Street 2:VETERAN'S MEMORIAL BUILDING, 2ND FLOOR
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:315-366-2599
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health