Provider Demographics
NPI:1932694734
Name:GIBSON, SARA (LAC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 E NORTHERN AVE UNIT 114
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3984
Mailing Address - Country:US
Mailing Address - Phone:602-846-5123
Mailing Address - Fax:
Practice Address - Street 1:4750 N CENTRAL AVE STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1755
Practice Address - Country:US
Practice Address - Phone:602-846-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-22707101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional