Provider Demographics
NPI:1891332185
Name:GIBSON, TIERRA L (RBT)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 OAKHURST DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5242
Mailing Address - Country:US
Mailing Address - Phone:260-459-6040
Mailing Address - Fax:260-459-6010
Practice Address - Street 1:6131 N CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4905
Practice Address - Country:US
Practice Address - Phone:260-459-6040
Practice Address - Fax:260-459-6010
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician