Provider Demographics
NPI:1134365497
Name:GIBSON, THERESA L (PHD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:GIBSON
Other - Last Name:KEISLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11111 CARMEL COMMONS BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5319
Mailing Address - Country:US
Mailing Address - Phone:704-540-5411
Mailing Address - Fax:704-540-4933
Practice Address - Street 1:11111 CARMEL COMMONS BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5319
Practice Address - Country:US
Practice Address - Phone:704-540-5411
Practice Address - Fax:704-540-4933
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2607103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent