Provider Demographics
NPI:1790061422
Name:GIBBONS, CHRISTIN J (LMFT)
Entity Type:Individual
Prefix:
First Name:CHRISTIN
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E OLIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1467
Mailing Address - Country:US
Mailing Address - Phone:608-316-1186
Mailing Address - Fax:608-252-1333
Practice Address - Street 1:128 E OLIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713-1467
Practice Address - Country:US
Practice Address - Phone:608-316-1186
Practice Address - Fax:608-252-1333
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI864-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist