Provider Demographics
NPI:1033934641
Name:GIBSON, STARR'RETIECE R (LICENSED DIETITIAN)
Entity type:Individual
Prefix:
First Name:STARR'RETIECE
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:F
Credentials:LICENSED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 GOOSE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAUGET
Mailing Address - State:IL
Mailing Address - Zip Code:62206-2822
Mailing Address - Country:US
Mailing Address - Phone:618-332-0953
Mailing Address - Fax:
Practice Address - Street 1:2071 GOOSE LAKE RD
Practice Address - Street 2:
Practice Address - City:SAUGET
Practice Address - State:IL
Practice Address - Zip Code:62206-2822
Practice Address - Country:US
Practice Address - Phone:618-857-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.008825133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered