Provider Demographics
NPI:1982840112
Name:GIBSON, EARL
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26421 PEPPERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26421 PEPPERWOOD LN
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1133
Practice Address - Country:US
Practice Address - Phone:860-309-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016854074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health