Provider Demographics
NPI:1922592997
Name:GIBSON, DEBRA JEAN (LSUDC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:JEAN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5689 S REDWOOD RD UNIT 30
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5499
Mailing Address - Country:US
Mailing Address - Phone:801-268-1715
Mailing Address - Fax:
Practice Address - Street 1:5689 S REDWOOD RD UNIT 30
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84123-5499
Practice Address - Country:US
Practice Address - Phone:801-268-1715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6926577-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)