Provider Demographics
NPI:1891573770
Name:GIBSON WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:GIBSON WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-651-0090
Mailing Address - Street 1:1935 QUARTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301-2319
Mailing Address - Country:US
Mailing Address - Phone:586-651-0090
Mailing Address - Fax:
Practice Address - Street 1:801 W BIG BEAVER RD STE 208
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4726
Practice Address - Country:US
Practice Address - Phone:586-651-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty