Provider Demographics
NPI:1942453519
Name:GIBSON, THERESA R (LMSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-1710
Mailing Address - Country:US
Mailing Address - Phone:989-255-3505
Mailing Address - Fax:
Practice Address - Street 1:156 S 3RD ST
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1710
Practice Address - Country:US
Practice Address - Phone:989-255-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010816871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical