Provider Demographics
NPI:1891037784
Name:GIBSON, COREY L (MA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 JUDSON RD STE 103-A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-2938
Mailing Address - Country:US
Mailing Address - Phone:903-238-9050
Mailing Address - Fax:
Practice Address - Street 1:1705 JUDSON RD STE 103-A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-2938
Practice Address - Country:US
Practice Address - Phone:903-238-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional