Provider Demographics
NPI:1023603768
Name:GIBSON, STACIE LEVINE
Entity type:Individual
Prefix:MS
First Name:STACIE
Middle Name:LEVINE
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 1:2911 BENCHMARK TRL
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5918
Mailing Address - Country:US
Mailing Address - Phone:254-535-0727
Mailing Address - Fax:
Practice Address - Street 1:2911 BENCHMARK TRL
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5918
Practice Address - Country:US
Practice Address - Phone:254-535-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8455101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)