Provider Demographics
NPI:1013940642
Name:GIBSON, GREGORY SCOTT (MA, LPCC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:SCOTT
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 BROTHERS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6975
Mailing Address - Country:US
Mailing Address - Phone:505-982-6728
Mailing Address - Fax:505-982-6728
Practice Address - Street 1:2204 BROTHERS RD
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6975
Practice Address - Country:US
Practice Address - Phone:505-982-6728
Practice Address - Fax:505-982-6728
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11071101YP2500X
NM0151831101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional