Provider Demographics
NPI:1952834434
Name:GIBSON, MOLLIE (QASP)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:QASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6816 SOUTHPOINT PKWY
Mailing Address - Street 2:BLDG 500
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1700
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:
Practice Address - Street 1:10175 FORTUNE PKWY
Practice Address - Street 2:SUITE 903
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6746
Practice Address - Country:US
Practice Address - Phone:904-538-0713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8538106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst