Provider Demographics
NPI:1245667062
Name:GIBSON, ZACHARY MCCORMICK
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:MCCORMICK
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 1:5511 STAPLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5445
Mailing Address - Country:US
Mailing Address - Phone:804-523-6242
Mailing Address - Fax:
Practice Address - Street 1:5511 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5445
Practice Address - Country:US
Practice Address - Phone:804-523-6242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008779101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health