Provider Demographics
NPI:1942740519
Name:GIBSON, SALOME
Entity Type:Individual
Prefix:
First Name:SALOME
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 W 32ND ST
Mailing Address - Street 2:APT 12C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224
Mailing Address - Country:US
Mailing Address - Phone:718-877-9133
Mailing Address - Fax:
Practice Address - Street 1:3025 W 32ND ST
Practice Address - Street 2:APT 12C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1746
Practice Address - Country:US
Practice Address - Phone:718-877-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY770353131103K00000X, 174H00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174H00000XOther Service ProvidersHealth Educator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program