Provider Demographics
NPI:1811372667
Name:GIBSON, GINAVRA
Entity Type:Individual
Prefix:
First Name:GINAVRA
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 1:301 PALMETTO PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7872
Mailing Address - Country:US
Mailing Address - Phone:803-359-3545
Mailing Address - Fax:803-359-2111
Practice Address - Street 1:119A MALIBU DR
Practice Address - Street 2:
Practice Address - City:BATESBURG
Practice Address - State:SC
Practice Address - Zip Code:29006-2121
Practice Address - Country:US
Practice Address - Phone:803-532-8414
Practice Address - Fax:803-532-4570
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health